THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 
MRS.  PRUDENCE  W.  KOFOID 


A     TREATISE 


TOPOGRAPHICAL     ANATOMY; 


THE      ANATOMY 


REGIONS   OF  THE  HUMAN   BODY, 


SURGERY    AND    OPERATIVE    MEDICINE, 


WITH    AN    ATLAS    OF    TWELVE    PLATES. 


BY     PH.     FRED.     BLANDI'N, 

PROFESSOR  OK  ANATOMY  AND  OPERATIVE  MEDICINE,  ETC. 


TRANSLATED   FROM   THE    FRENCH, 

BY    A.    SIDNEY    DOANE,    A.M.  M.  D. 

WITH   ADDITIONAL   MATTER   AND  PLATES. 


NEW     YORK: 

MOORE    &   PAYNE,   UNIVERSITY    BOOKSTORE,    CLINTON    HALL. 
COLLINS   &   HANNAY,   230    PEARL    STREET. 

M  DCCC  XXXIV. 


«.    ft    '1 


Entered  according  to  the  Act  of  Congress,  in  the  year  1833,  by 
MOORE  &  PAYNE, 

in  the  Clerk's  office  of  the  District  Court  of  the  United  States,  for  the  Southern" 
District  of  New  York. 


SLEIGHT   &  VAN    NORDEN, 


TO 


GEORGE    B.     DOANE,    A.M.,    M.  D.,    M.  M.  S. 


MY    DEAR    SIR, — 

IN  dedicating  this  translation  to  you,  allow  me  to  express  my 
respect  for  your  talents  and  acquirements :  your  classical  acquaintance 
with  the  modern  languages  has  opened  to  you  sources  of  professional 
information  which  are  closed  to  many;  while  your  mind  is  well 
stored  with  facts,  gleaned  by  years  of  laborious  practice,  both  at  home 
and  abroad.  You  are  now  actively  engaged  in  the  cause  of  humanity ; 
and,  while  expressing  a  wish  that  your  merits  may  be  properly  appre- 
ciated, your  exertions  richly  rewarded,  may  I  ask  the  continuance  of 
your  valued  friendship  ? 

With  much  esteem, 

A.  SIDNEY  DOANE, 


59,  v* 


PREFACE. 


THE  object  of  BlandirCs  Treatise  on  Topographical  Anatomy,  a 
translation  of  which  is  now  offered  to  the  medical  profession,  is,  "  to 
examine  the  organs  in  each  part  of  the  body,  leaving  out  of  view  their 
analogies :  in  other  words,  to  study  the  regions  formed  by  nature, 
which  are  always  combined  so  as  to  place  the  organs  in  as  little  space 
as  possible,  without  injuring  the  action  of  any  of  them.  This  science 
has  been  pursued  by  men  of  great  talent ;  its  elements  are  for  the  most 
part  known,  and  are  mentioned  in  the  excellent  treatises  in  descriptive 
anatomy  of  Meckel,  Beclard,  Lawrence,  Cooper,"  &c.  &c.  The  plan 
pursued  by  Blandin,  as  stated  in  his  preface,  is  as  follows :  "  Since 
the  elements  of  topographical  anatomy,"  he  says,  "  are  derived  from 
descriptive  anatomy,  we  have  carefully  refrained  from  encroaching 
upon  the  bounds  of  this  latter  science.  In  this  respect,  we  have 
followed  strictly  the  plan  of  Beclard,  who  delivered  several  courses  of 
lectures  on  this  subject.  The  details  of  descriptive  anatomy,  in  each 
region,  are  but  few,  and  are  presented  merely  to  refresh  the  mind  of 
the  reader :  sometimes,  however,  we  have  varied  from  this  course ; 
first,  as  when  examining  parts  not  described  in  descriptive  anatomy, 
as  the  aponeuroses :  second,  when  the  descriptions  commonly  given 
are  imperfect :  third,  when  stating  new  or  curious  details  :  we  have 
also  mentioned  the  varieties  of  the  animal  tissues,  when  speaking  of 
the  different  regions. 

"  It  follows,  from  these  remarks,  that  a  work  of  this  kind  cannot  be 
studied,  except  by  those  who  have  some  knowledge  of  anatomy,  and 
cannot  take  the  place  of  a  work  on  descriptive  anatomy :  for,  either  it 
includes  all  the  special  details  of  the  organs,  and  then  it  is  not  a  work 
on  topographical  anatomy,  but  a  treatise  on  descriptive  anatomy,  in 
which  the  arrangement  is  bad :  or,  the  descriptive  details  are  very 
brief,  and  insufficient  for  those  who  wish  to  study  the  special  structure 
of  the  organs. 

"  The  method  of  description  followed  in  this  work  is  the  synthe- 
tical :  from  general  remarks  on  the  human  body  we  have  descended 
to  its  secondary  divisions,  and  then  to  the  regions,  where  we  have 
entered  upon  the  true  details  of  topographical  anatomy. 


6  PREFACE. 

"  Such  is,  briefly,  the  plan  of  this  work,  in  which  we  have  attempted 
to  establish  the  important  relations  of  anatomy  with  medicine,  and 
particularly  with  surgery.  For  the  details,  we  have  consulted  the 
works  of  the  most  eminent  anatomists  and  surgeons  of  the  age  ;  while 
every  assertion  has  been  verified  by  the  scalpel,  which  has  led  to  some 
interesting  discoveries :  occasionally,  we  have  attempted  to  render  the 
subject  less  dry,  by  references  to  comparative  anatomy ;  and  in  order 
to  make  the  description  of  the  most  important  and  complex  regions 
more  intelligible,  drawings  of  them  have  been  made  from  nature,  by 
Jacob,  one  of  the  ablest  artists  in  France. 

"  Finally,  this  work  is  designed  for  medical  students  generally :  it 
will  be  found  of  assistance  in  dissections,  inasmuch  as  each  region 
presents,  in  distinct  articles,  every  thing  in  respect  to  its  external  or 
internal  form,  and  to  the  elements  and  relations  of  its  structure ;  these 
subjects  should  be  investigated  in  the  dissecting  room;  while  our 
remarks  upon  the  development  and  uses  of  the  regions,  and  the  patho- 
logical and  operative  deductions,  can  be  studied  in  private,  and  are 
naturally  deduced  from  the  former." 

In  regard  to  the  American  translation  we  would  state,  that  a  treatise 
on  Topographical  Anatomy  being  called  for  by  the  profession,  we 
selected  the  work  of  Blandin,  which  is  considered,  by  the  best  judges, 
to  be  extremely  valuable.  It  has  been  translated  with  the  utmost 
care ;  the  errors  of  the  original  have  been  corrected  ;  a  few  alterations 
have  been  made,  in  which  we  have  followed  strictly  the  plan  of  the 
author.  Four  new  plates  have  been  added.  One  from  Watts ;  A 
perpendicular  section  of  the  head  and  neck,  to  show  the  relative 
situations  of  the  cavities  of  the  Nose,  Mouth,  Larynx,  and  Pharynx ; 
a  second,  Illustrating  those  parts  of  the  eye  most  concerned  in  surgical 
operations  ;  a  third,  A  front  view  of  the  Axilla  ;  a  fourth,  from  Scarpa, 
Illustrating  the  anatomy  of  Hernia.  These,  it  is  thought,  will  render 
our  translation  still  more  valuable. 

Before  concluding,  however,  we  would  call  the  attention  of  our  readers 
to  the  mechanical  execution  of  the  work,  which  is  extremely  fine :  the 
plates  have  been  drawn  in  a  style  of  uncommon  beauty,  by  Mr.  D.  G. 
Johnson,  an  artist  of  great  merit,  while  the  typography  is  unsurpassed 
by  any  medical  work  in  this  country. 

December  17,  1833. 


1 


CONTENTS. 


INTRODUCTION 

Table  of  Regions 

Human  body 

PART  I.     Trunk 

SECT.  I.     Extremities  of  the  Trunk 

CHAP.  I.    Head 

ART.    I.     Cranium 

PAR.    I.     Parietes  of  the  Cranium 

ORD.    I.     Arch  of  the  Cranium 

Occipito-Frontal  region 
ORD.  II.     Lateral  wall  of  the  Cranium 

1.  Temporal  region 

2.  Auricular  region 

3.  Mastoid  region     - 
ORD.  III.    Inferior  wall  of  the  Cranium 

Region   of   the   base  of  the 

Cranium 

PAR.  II.     Cavity  of  the  Skull 
ART.  II.     Face 
PAR.    I.     Nostrils 

1.  External  Olfactory  region, 

(Nose) 

2.  Internal  Olfactory  region, 
(Nasal  fossae) 

PAR.  II.    Mouth    - 

1.  Palatine  region    - 

2.  Palatal  region 

3.  Labial  region 

4.  Mental  region 

5.  Malar  region 

6.  Tonsillar  region 
PAR.  III.     Orbits 

1.  Ext.  Orbitar  region 

2.  Int.  Orbitar  region 


PAGE 

PAGE 

9 

PAR.  IV. 

Zygomatic  fossa                       102 

19 

CHAP.  II. 

Coccygreal  extremity  of  the 

21 

Trunk                                    105 

27 

SECT.  II. 

Central  portion  of  the  Trunk    106 

32 

CHAP.  I. 

Neck     ~            -                       106 

32 

ART.    I. 

Tracheal  portion  of  the  neck     109 

33 

PAR.    I. 

Natural  regions  of  the  anterior 

35 

part  of  the  neck    -                 114 

35 

ORD.   I. 

Natural  regions  of  the  Supra- 

35 

Hyoid  part  of  the  neck     -     1  14 

42 

1.  Glosso-supra-hyoid  region    114 

42 

2.  Parotid  region                       119 

46 

ORD.  II. 

Natural  regions  of  the  Infra- 

52 

Hyoid  part  of  the  neck           123 

54 

1.  Laryngo-Tracheal  region     123 

e 

2.  Supra-Clavicular  region        131 

54 

PAR.  II. 

Artificial  regions  of  the  Tra- 

56 

cheal  portion  of  the  neck        136 

59 

1.  Sterno-Mastoid  region         137 

62 

2.  Carotid  region     -            -     140 

» 

ART.  II. 

Posterior  portion  of  the  neck      145 

64 

Region  of  the  Nucha            -     145 

i 

CHAP.  II. 

Chest      -                                    149 

66 

ART.    I. 

Parietes  of  the  Thorax          -     152 

69 

1.  Costal  region              -           152 

70 

2.  Sternal  region      -            -.160 

72 

3.  Dersal  region                         163 

73 

4.  Diaphragmatic  region      -     166 

77 

5.  Upper  wall  of  the  Thorax     169 

73 

ART.  II. 

Cavity  of  the  Chest          -           170 

88 

PAR.     I. 

Mediastinal  region  -            -     170 

89 

Pulmonary  Cavities        -           176 

90 

CHAP.  III.  Abdomen     -                         -     179 

95 

ART.    I. 

Abdominal  parieten                   ISO 

B                                                              CONTENTS. 

PA.OK 

PAR.     I. 

Anterior  and  lateral  abdomi- 

nal parietes 

182 

CHAP.  II. 

Costo-Iliac  region 

182 

PAR.  II. 

Posterior  abdominal  wall 

191 

1.  Lumbar  region 

191 

2.  Iliac  region 

196 

CHAP.  III. 

Groin      - 

199 

PAR.  III. 

Superior  abdominal  wall 

202 

PAR.  IV. 

Inferior  abdominal  wall 

202 

ORD.    I. 

Perineum 

203 

CHAP.  IV.] 

1.  General  remarks 

203 

1.  Perineum  in  the  male 

209 

2.  Perineum  in  the  female 

217 

SEC.  II.     . 

ORD.  II. 

Circumference  of  the  pelvis 

221 

CHAP.  I. 

1.  Intra-pelvic  portion     - 

222 

2.  Extra-pelvic  portion 

224 

1.  Posterior  sacral  region 

224 

CHAP.  II. 

2.  Pubic  region  - 

226 

3.  External  Genital  organs 

227 

1.  Testicular      or      Scrotal 

region 

227 

CHAP.  III. 

2.  Region  of  the  Penis 

230 

ART.  II. 

Abdominal  Cavity 

233 

PART  II. 

Limbs          ... 

246 

SEC.    I. 

Thoracic  limbs 

249 

CHAP.  IV. 

CHAP.  I. 

Shoulder      ... 

251 

1.  Clavicular  region 

251 

2.  Scapular  region 

253 

3.  Scapulo-humeral  region 

256 

PAM 

4.  Axillary  region    -  -     261 

Second  part  of  the  thoracic 
limb          -  -  -    267 

1.  Brachial  limb  267 

2.  Region  of  the  Elbow        -     272 
Third   part   of  the   thoracic 

limb  -  -    280 

1.  Anti-brachial  region  -          280 

2.  Region  of  the  Wrist  -    286 
Hand      -  291 

1.  Palmar  region     -  -    292 

2.  Digital  region  297 
Abdominal  limbs      -            -     304 
First  section  of  the  abdominal 

limbs  ...  306 
1.  Gluteal  region  -  308 

Second  part  of  the  abdominal 

limb         -  -    312 

1.  Crural  region  312 

2.  Knee       -  -  -    326 
Third  part  of  the  abdominal 

limb  -     336 

1.  Leg   -  336 

2.  Ankle      -  -     345 
Fourth  section  of  the  abdomi- 
nal limbs         -            .          354 

1.  Region  of  the  Sole  of  the 
Foot         -  -  -    355 

2.  Toes  -  363 


INTRODUCTION 


ALTHOUGH  the  number  of  bodies  on  the  surface  of  the  globe  is  great, 
yet  they  may  be  divided  into  two  large  classes:  the  first  includes 
inanimate  objects,  the  second,  organized  bodies :  the  former  are 
aggregates,  formed  by  the  influence  of  attraction ;  the  latter,  although 
subjected  to  physical  laws,  are  composed  of  elements  which  would 
rapidly  separate,  were  they  not  united  by  a  power,  the  principle  of 
which  is  unknown  While  its  effects  are  palpable :  the  vital  power. 

The  general  knowledge  of  nature,  or  natural  philosophy,  is  based 
on  the  analogies  presented  by  all  these  bodies,  and  is  divided  into  two 
great  sections,  one  of  which  treats  of  the  inanimate  objects,  the  other 
of  the  organized  bodies. 

The  science  of  the  organized  bodies  is  the  more  interesting  and 
more  useful  to  the  physician :  the  subjects  on  which  it  treats  are  of 
two  kinds,  and  are  either  vegetable  or  animal ;  these  differ  princi- 
pally in  the  power  of  sensation,  which  exists  only  in  the  latter.  Some- 
times this  science  treats  particularly  of  their  classes,  their  manners, 
and  their  habits :  sometimes  of  their  structure :  finally,  sometimes  it 
points  out  only  the  action  of  their  organs,  in  natural  history,  anatomy, 
or  physiology,  three  sciences,  which,  although  very  distinct,  present 
many  points  of  resemblance.  Of  these,  anatomy  is  undoubtedly  the 
first  and  most  useful :  it  serves  as  the  base  of  the  other  two,  and  fur- 
nishes a  great  number  of  facts,  useful  in  the  study  and  treatment  of 
diseases :  in  fact,  the  physician  should  be  intimately  acquainted  with 
the  organs  in  their  healthy  state,  in  order  to  estimate  properly,  their 
numerous  and  varied  morbid  alterations.  Anatomy  is  particularly 
necessary  to  the  surgeon :  when  he  plunges  his  knife  into  a  part,  he 
should  be  able  to  guide  it  with  as  much  boldness,  as  if  the  whole  body 
were  transparent,  and  he  could  follow  its  course  with  his  eye. 

Anatomy,  in  its  most  extensive  sense,  embraces  the  whole  organic 
kingdom,  and  treats  of  the  generalities  of  the  structure  of  all  the 
2 


10  INTRODUCTION. 

beings  which  compose  it :  when  this  general  anatomy  is  studied  in  a 
narrower  point  of  view,  and  we  refer  to  a  single  class  or  species  (in 
order  to  know  particularly  its  minute  structure,)  the  ideas  we  have  of 
the  structure  of  all  the  others,  it  is  termed  comparative  or  compared 
anatomy. 

Anatomy,  then,  in  its  most  general  sense,  is  divided  into  phytotomy, 
which  treats  of  the  peculiar  structure  of  vegetables,  and  zootomy, 
which  embraces  that  of  animals :  these  great  divisions  also  are  more 
or  less  subdivided,  according  as  the  organization  is  studied  more 
minutely :  and  finally,  we  arrive  at  the  examination  of  one  species, 
which  is  special  anatomy,  in  which  class  is  found  anthropotomy. 
These  are  the  divisions  generally  admitted  in  anatomical  science ; 
but  we  must  allow  that  they  are  by  no  means  so  strict  as  they  appear  • 
to  be  at  first  view :  in  fact,  as  they  are  established  on  the  classes, 
families,  genera  and  species  of  the  organic  kingdom,  they  have  no 
foundation  except  that  presented  by  these  latter.  But  these  classes, 
families,  &c.,  although  formed  as  well  as  they  can  be,  are  merely 
simple  abstractions,  made  to  facilitate  their  study.  To  understand  this 
truth  completely,  let  us  examine  the  extremity  of  the  organic  king- 
dom :  we  there  see  that  the  naturalist  is  embarrassed  in  deciding  upon 
the  place  to  be  occupied  by  certain  beings,  species  of  hermaphrodites, 
which  do  not  belong  to  any  one  of  the  great  classes  of  natural  bodies, 
more  than  to  another ;  hence,  men  of  science  have  been  led  by  these 
facts,  to  consider  the  different  individuals  of  the  organic  kingdom  as 
forming  only  one  great  family,  in  which  they  must  be  arranged  in 
the  orders  of  their  affinities  ;  thus  forming  a  kind  of  scale  with  imper- 
ceptible but  continuous  gradations,  from  man,  who  occupies  the 
summit,  to  the  most  simple  vegetables  which  mark  the  lowest  degrees. 
Each  being  in  the  adult  or  perfect  state,  occupies  a  more  or  less 
elevated  determinate  degree,  in  this  organic  scale ;  but  a  remarkable 
fact  has  been  established  by  the  profound  labors  of  Tiedemann, 
Meckel,  and  many  others ;  viz.,  that  it  passes  through,  in  the  course 
of  its  development,  several  of  the  degrees  which  are  lower  than  that 
properly  belonging  to  it,  and  successively  assumes,  by  more  or  less 
evident  changes,  states  which  other  organized  beings  permanently 
possess. 

Hence,  in  an  anatomical  description,  we  ought  to  note  carefully  the 
actual  ages  of  the  beings  examined,  if  we  do  not  wish  to  place  in  one 
degree  of  the  organic  scale  a  body  which  really  belongs  to  another  : 
descriptions  should  always  be  based  upon  the  adult  or  perfect  state :  in 
fact,  we  ought  first  to  consider  abstractly  the  varieties  belonging  to 
individuals  and  to  sexes,  which,  however,  as  well  as  the  differences 
depending  on  development,  should  be  carefully  noted. 


INTRODUCTION.  ".  11 


OF    THE    ANATOMY    OF    MAN. 

Human  anatomy,  or  anthropotomy,  to  which  we  shall  now  attend, 
is,  therefore,  only  a  small  division  of  the  general  science  of  the  organi- 
zation, and  it  has  for  its  object,  the  knowledge  of  those  beings  who 
stand  first  in  the  scale. 

Dissection,  the  only  mode  of  gaining  a  profound  knowledge  of  ana- 
tomy, has  been  carried  to  such  perfection,  that  in  order  to  describe 
the  human  body  by  commencing  at  its  elementary  parts,  we  must 
begin  far  beyond  the  attainments  even  of  very  modern  anatomists.  We 
shall  not  mention  the  microscopic  globules,  which  have  been  studied 
by  Leuwenoech  and  Hewson  particularly,  and  which  seem  to  attract 
anew  the  attention  of  scientific  men ;  these  have  been  found  by  Milne 
Edwards  to  be  similar  in  all  the  tissues — presenting  in  every  part  one 
three  hundredth  of  a  millimeter  in  diameter ;  these  globules  are  not 
true  anatomical  elements:*  our  organs  are  composed  of  a  certain 
number  of  fibres,  which  unite  in  various  modes  to  form  the  simple 
organs  or  elementary  tissues,  while  these  combine  and  give  rise  to 
complex  organs,  which,  collectively,  form  the  regions  and  the  whole 
body.  The  elementary  fibres  generally  admitted  are  three :  viz.,  the 
cellular,  the  contractile,  and  the  nervous.  The  author  of  ^  Nomen- 
clature Anatomlque  Moderne"  adds  also  the  albugineous  fibre,  which 
he  considers  with  Beclard,  as  a  more  or  less  remote  modification  of 
the  cellular  fibre,  grounding  his  opinion  on  its  -development,  its  chem- 
ical composition,  and  the  phenomena  which  attend  its  decomposition 
by  maceration.  Blainville  goes  still  farther :  he  admits  only  the  cel- 
lular and  the  nervous  fibre,  and  considers  the  contractile  fibre  only  as 
a  modification  of  the  former :  in  fact,  he  remarks,  that  the  lowest 
animals  move,  although  they  have  no  muscles,  and  the  motions  are 
produced  by  the  cellular  fibre.  This  opinion  of  Blainville,  which  at 
first  view  appears  singular,  deserves  much  more  serious  attention, 
because  in  some  parts  of  man,  the  .cellular  tissue  becomes  semi- 
contractile,  as  in  the  dartos,  and  in  other  cases,  we  find  a  tissue, 
which,  in  respect  to  its  properties  and  chemical  composition,  seems  to 
establish  the  transition  between  the  cellular  and  muscular  tissues  ;t 

*  The  chemical  elements  of  the  animal  tissues  are  principally  oxygen,  hydrogen,  carbon, 
and  azote;  simple  bodies,  to  which  others  are  added.  These  elements  combine,  and  form 
the  immediate  principles,  which  become  in  their  turn  the  base  of  the  anatomical  elements. 

t  We  have  frequently  observed  a  small  muscle  extended  between  the  styloid  process  and 
the  top  of  the  small  horn  of  the  hyoid  bone,  in  place  of  the  stylo-hyoid  ligament  As  this 
ligament  is  formed  in  the  normal  state  of  elastic  fibrous  tissue,  we  can  easily  conceive  of  its 
change  into  a  muscle. 


12  INTRODUCTION. 

this  is  the  yellow  fibrous  or  elastic  tissue,  which  contains  a  good  deal  of 
fibrin.  We  shall  not  mention  the  unique,  invisible,  and  ideal  fibre  of 
the  ancients,  which  they  considered  as  formed  of  water,  earth,  and  fire. 

The  organs,  solid  parts,  which  have  an  action  in  the  system,  are 
very  numerous  ;  they  are  divided  into  simple  and  complex  organs : 
the  simple  organs  are  generally  distributed  over  a  great  many  parts 
of  the  body,  and  their  structure  is  simple,  being  cellular,  adipose, 
Jibrous,  The  complex  organs  are  formed  of  a  variable  number  of 
simple  organs,  to  which  are  added  other  complex  organs,  as  the 
vessels,  &c.  The  stomach,  for  instance,  is  a  complex  organ,  formed 
of  the  cellular,  and  serous  tissues,  &c.,  simple  organs,  to  which  are 
added  vessels  and  nerves,  complex  organs. 

The  simple  organs,  which  are  distributed  generally  in  the  human 
body,  present  a  great  number  of  analogies :  the  complex  organs  offer 
others,  which,  although  less  numerous,  are  not  less  real :  hence  the 
idea  of  uniting  in  one  branch  of  science  all  these  generalities  of 
organic  bodies,  to  which  we  owe  general  anatomy,  or  rather  the 
general  anatomy  of  the  organs,  which  may  be  defined  the  science  of 
the  generalization  of  the  organs.  Bichat,  in  his  immortal  work,  when 
speaking  of  the  simple  organs,  as  the  cellular  tissue  and  the  fat,  does 
not  confine  himself  to  general  remarks,  but  enters  into  particulars  on 
these  tissues  considered  in  respect  to  the  regions :  he  consequently 
encroaches  on  the  domain  of  topographical  anatomy,  which  is  now 
established  and  claims  these  particulars,  which  do  not  belong  to  the 
science  of  the  generalization  of  the  organs. 

The  description  of  the  internal  and  external  forms,  and  also  of  the 
structure  and  development,  of  the  complex  organs,  is  the  subject  of 
descriptive  anatomy,  for  which  the  special  anatomy  of  the  organs 
would  be  a  better  term ;  for  the  descriptive  mode  is  far  from  being 
confined  to  this  alone.  Finally,  the  particulars  of  the  simple  organs 
and  the  general  remarks  on  the  grouping  of  all  the  organs,  form  the 
elements  of  topographical  anatomy. 

We  distinguish  three  species  of  groups  of  organs :  the  system, 
the  apparatus,  and  the  region,  of  organs.  The  system  is  an 
imaginary  group  of  analogous  organs,  from  which  some  remote 
considerations  are  deduced:  the  apparatus  is  a  natural  group 
formed  of  organs  which  take  part  in  the  same  function :  this  comes 
within  the  province  of  physiology,  or  rather  of  descriptive  physio- 
logical anatomy.  Finally,  the  region  is  also  a  group  formed  natu- 
rally, (sometimes  in  a  physiological  point  of  view,  sometimes  from 
their  locality ;)  by  organs  which  frequently  present  but  slight  analogy 
of  form  and  structure :  it  belongs  to  topographical  anatomy. 


INTRODUCTION.  .:  13 


OF    TOPOGRAPHICAL   ANATOMY. 

Topographical  anatomy,  or  the  anatomy  of  the  regions,  to  which 
alone  we  shall  attend,  may  be  defined,  the  science  of  the  local  organi- 
zation. It  has  for  its  subject  the  groups  of  organs  of  the  third  order. 
The  purpose  of  topographical  anatomy  is  the  knowledge  of  the 
regions  and  of  the  whole  body  considered  by  masses ;  but  in  order  that 
this  purpose  may  be  completely  attained,  it  does  not  treat  merely  of 
the  relations  of  organs  in  the  different  parts  :  still  less  must  we  merely 
describe  them  by  regions :  but  we  must  examine  minutely  the  whole 
formed  by  their  local  union.  Farther,  from  the  avowed  purpose  of 
topographical  anatomy,  viz.,  the  particulars  of  the  simple  tissues  con- 
sidered according  to  their  regions,  and  general  remarks  on  the  organic 
groups  which  constitute  the  latter,  it  is  evident  that  this  important 
branch  of  anatomy  supposes  as  known,  the  generalities  of  all  the 
organs,  and  the  particulars  of  the  complex  organs,  or  general  ana- 
tomy, and  descriptive  anatomy :  hence  it  would  be  absurd  to  com- 
mence the  science  of  the  organization  by  the  branch  of  which  we 
are  treating ;  this  would  be  to  attempt  to  study  the  most  complicated 
of  all  the  machines  by  merely  inspecting  it  externally,  and  before 
acquiring  a  minute  knowledge  of  its  different  wheels. 

Topographical  anatomy  has  been  termed  also,  surgical  anatomy, 
the  anatomy  of  relations,  fyc.  The  first  term  is  founded  on  its  direct 
importance  to  the  surgeon ;  but  as  topographical  anatomy  is  also 
sometimes  useful  to  the  physician,  especially  as  it  belongs  necessarily 
to  every  complete  course  of  anatomy,  it  follows,  that  like  many  other 
scientific  terms,  this  term  is  improper,  because  it  limits  the  idea  of  the 
science  of  the  regions.  The  term  the  anatomy  of  relations,  is  not  SQ 
bad :  but  it  is  also  defective,  as  it  supposes,  a  priori,  that  the  relations 
of  contiguity  are  alone  to  be  considered.  The  term  topographical 
anatomy  does  not  confine  the  subject  of  the  science ;  it  is  most  suit- 
able, and  farther,  it  is  sanctioned  by  Meckel,  Roux,  Beclard,  Cloquet, 
and  others. 


14  INTRODUCTION. 


OF   THE  REGION   IN   GENERAL. 

A  region  is  a  more  or  less  extensive  space,  with  more  or  less  exact 
and  natural  bounds.  In  topographical  anatomy,  this  term  is  applied  to 
the  different  sections  of  the  body,  which  are  to  be  examined  by  the 
anatomist. 

The  surface  of  the  human  body  is  very  extensive,  and  the  regions 
which  compose  it  are  very  numerous.  We  can  conceive  that  their 
number  may  be  very  great,  simply  from  the  definition,  since  an  anato- 
mist may  divide  a  single  region  into  two  or  three  which  are  smaller. 
Still  the  bases  of  the  topographical  division  of  the  body  are  more 
certain  than  they  at  first  seem :  and  when  we  reflect  maturely,  we 
easily  discover  that  nature  herself  has  often  marked  them  by  ridges  of 
bone,  or  by  muscular  prominences  and  depressions :  and  we  particu- 
larly observe,  that  around  each  important  part  of  the  skeleton,  a  num- 
ber of  organs  generally  seek  support.  We  have  constantly  used  these 
bases  of  the  general  arrangement  of  the  organs  for  the  establishment 
of  the  regions,  which  were  also  the  bases  of  the  divisions  admitted  by 
Beclard,  in  his  lectures. 

By  forming  the  regions  in  this  manner,  they  are  natural,  and  more 
simple  for  the  pupil  who  wishes  to  study  them,  since  it  is  much  more 
easy  to  determine  the  place  where  his  investigations  must  cease ;  they 
give  rise  particularly  to  more  extensive  remarks  in  respect  to  their  uses, 
and  to  the  action  of  their  organs,  or  in  their  applications  to  medicine. 
Who,  for  instance,  can  hesitate  upon  the  impropriety  of  separating 
the  axilla  into  several  regions,  or  of  uniting  in  one  the  groups  of 
organs  formed  around  the  clavicle,  the  scapula,  and  their  union  with 
the  trunk?  If  the  anterior  and  lateral  abdominal  parietes  were  divided 
into  several  regions,  should  we  not  be  obliged  to  state  in  each  of  them, 
that  we  always  found  the  skin,  fascia  superficialis  and  obliquus  ab- 
dominis  externus  muscle  ?  Does  not  the  inconvenience  which  would 
follow  in  generalizing  the  uses  of  this  wall,  in  vomiting  for  instance,  or 
in  examining  its  alterations  in  many  cases,  prove  this  ?  How  incon- 
venient it  would  be  also  to  separate  the  thigh  into  several  regions  ? 
Not  to  mention  the  want  of  exact  boundaries  for  these  limits,  the  uses 
of  the  thigh  are  such,  that  only  a  bad  idea  of  them  can  be  formed  by 
dividing  them  and  referring  them  to  different  parts  :  and  finally,  when 
for  instance,  we  wished  to  ascertain  by  anatomy,  to  what  extent  after 
the  femoral  artery  was  tied,  the  circulation  could  be  re-established  in 
the  lower  part  of  the  limb,  we  should  have  to  call  to  mind  the  ana- 


INTRODUCTION.  15 

tomical  relations  of  all  parts  of  the  thigh,  since  the  collateral  arteries, 
which  are  then  so  useful,  are  distributed  in  every  part ;  hence  the 
pupil  would  find  it  extremely  difficult  to  know  to  which  crural  region, 
to  the  anterior,  to  the  posterior,  or  to  the  lateral,  he  must  refer  these 
important  deductions  of  pathological  anatomy.  Still  the  desire  for 
forming  regions  in  the  best  manner  for  obtaining  the  most  general 
deductions,  must  never  induce  us  to  include  in  one  region,  one  system 
of  organs,  unless  these  are  all  placed  exactly  in  the  same  situation,  as 
is  seen  in  the  external  and  internal  orbitar  regions.  We  must  not,  for 
instance,  include  the  maxillary  and  frontal  sinuses  in  the  internal 
olfactory  region,  although  they  make  part  of  the  olfactory  apparatus : 
this  in  fact  would  be  acting  contrary  to  the  simplest  rules  of  topo- 
graphical anatomy :  the  frontal  sinus  is  one  of  the  elements  of  the 
supraciliary  region ;  the  maxillary  sinus  belongs  to  the  skeleton  of  the 
cheek.  The  multiplicity  of  objects,  however,  in  certain  parts,  and  at 
the  same  time  the  necessity  of  exposing"  their  relations  minutely, 
sometimes  require  the  formation  of  artificial  sections,  in  order  to  con- 
fine their  examination  within  narrower  limits,  and  thus  to  facilitate  the 
study.  An  idea  of  the  division  of  the  human  body  into  regions,  and 
particularly  of  our  plan,  can  be  obtained  by  inspecting  the  table  at 
the  end  of  the  introduction. 

The  different  regions  also,  may  be  distinguished  into  natural  and 
artificial,  of  which  the  former  are  more  numerous  ;  and  as  there  are 
simple  and  compound  organs,  so  likewise  there  are  simple  and  com- 
pound regions ;  we  have  also  noted  in  another  place,  the  analogy 
between  the  regions  and  the  organs. 

All  the  regions  are  moulded  on  the  skeleton,  and  present  the  same 
general  arrangement :  some  are  elongated  as  those  of  the  limbs ;  others 
are  flat,  and  contribute  to  form  the  parietes  of  the  great  cavities  • 
finally,  others  are  short  and  thick. 

Every  region  should  be  considered  in  respect  to  its  external  form, 
its  depth,  direction,  breadth,  structure,  development,  varieties,  and 
uses ;  this  is  the  only  manner  of  deriving  from  the  topographical  study 
of  the  body,  all  the  advantages  in  respect  to  pathology  and  to  opera- 
tions that  we  have  a  right  to  expect ;  finally,  it  is  only  after  following 
a  region  in  all  its  details  that  we  can  resolve  the  problem  which  has 
been  so  long  proposed  by  surgeons,  viz.,  of  interpreting  operative 
medicine  by  anatomy. 

When  some  regions  contribute  to  form  a  cavity,  if  this  opens 
externally,  as  the  mouth,  we  must  first  describe  the  cavity ;  in  the 
contrary  case,  as  in  the  abdomen,  the  explanation  of  the* regions  must 
precede  that  of  the  cavity.  The  explanation  of  the  structure  of  a  re- 
gion embraces  two  things :  the  enumeration  of  its  component  elements, 


16  INTRODUCTION. 

and  the  minute  examination  of  their  relations  of  integrity ;  the  first 
part  is  merely  an  enumeration,  since  all  the  elements  of  a  region  are 
supposed  to  be  known,  and  are  described  in  treatises  on  descriptive 
anatomy  ;  however,  our  course  may  be  varied  by  circumstances. 

The  elements  of  a  region  must  not  be  enumerated  arbitrarily. 
Each  presents  resisting  parts  of  bone  or  of  some  other  character, 
which  form  its  skeleton  or  point  of  support ;  these  elements  should  be 
examined  first.  Next  come  always  the  more  or  less  muscular  parts, 
in  the  interstices  of  which  the  vessels  and  nerves  ramify ;  among  these  , 
some  only  pass  through  the  region,  and  go  elsewhere,  and  others 
terminate  in  it.  In  each  region,  the  vessels  communicate  by  more  or 
less  marked  anastomoses,  which  are  always  very  important)  because, 
being  frequently  formed  by  branches  which  arise  from  different  trunks, 
or  from  the  same  trunk  and  at  different  heights,  they  establish  in  the 
region  a  very  curious  collateral  circulation.  The  vessels  and  the 
nerves  of  most  of  the  regions,  come  from  trunks  which  also  furnish 
them  to  other  regions  more  or  less  adjacent,  which  circumstance 
causes  sympathetic  affections  of  different  kinds  between  them,  which 
it  is  also  very  important  to  notice.  In  all  the  regions  we  find  some 
cellular  tissue,  and  a  greater  or  less  quantity  of  adipose  vesicles,  which 
should  be  carefully  noted,  as  also  the  different  densities  of  the  simple 
organs,  not  only  in  the  region  generally,  but  also  in  its  different 
points.  Finally,  most  of  the  regions  present  an  external  face,  and 
consequently  a  part,  of  the  skin  enters  into  their  composition,  and  we 
have  to  consider  its  density  in  different  parts,  its  greater  or  less 
number  of  follicles,  and  the  hairs  which  cover  it. 

The  relations  of  the  organs  of  the  regions,  form  a  very  important 
part  of  topographical  anatomy,  and  are  universally  considered  as  such: 
but  we  have  satisfactorily  proved,  that  the  relations  are  far  from 
constituting  the  whole  of  this  science.  There  are  certain  regions 
Avhere  the  organs  form  very  well  marked  and  superimposed  layers, 
in  others  on  the  contrary  the  arrangement  differs.  In  the  former,  the 
study  of  the  relations  is  very  simple,  but  in  the  latter,  very  complex, 
This  study  of  the  layers  of  a  region  may  be  made  from  the  deep  to 
the  superficial  parts,  but  it  is  more  convenient  to  commence  in  the 
opposite  manner  ;  first,  because  in  dissection  the  superficial  layers  are 
divided  first ;  and  secondly,  because  in  operations,  the  surgeon  cuts  in 
this  direction.  In  regions  where  resisting  aponeuroses  exist  and 
form  the  sheaths  of  the  organs,  it  is  very  easy  for  the  study,  and  also 
for  the  description,  to  examine  successively  the  secondary  organic 
groups,  which  are  bounded  by  aponeurotic  layers ;  thus,  when  this 
method  is  applied  to  the  perineum,  it  simplifies  the  explanation  of  the 
complex  arrangement  of  the  organs  of  this  important  region  ;  in  the 


INTRODUCTION.  17 

limits,  also,  it  is  very  easy  to  consider  successively  the  relations  of  the 
organs  in  each  of  the  great  sheaths,  which  are  formed  by  the  large 
aponeuroses  existing  there. 

Each  region  presents  a  perfect  state,  which  must  be  considered  as 
the  type  of  the  first  description ;  but  to  arrive  at  this  state,  the  region, 
and  also  the  whole  individual,  passes  successively  through  a  certain 
number  of  periods  of  unquestionable  importance,  which  in  our  opinion 
will  be  demonstrated  in  the  course  of  this  work. 

Beside  the  more  or  less  apparent  variations  presented  regularly  by 
the  regions  considered  at  different  ages  of  life,  there  are  others  which, 
in  the  perfect  state,  depend  on  the  sexes,  and  finally  there  are  some 
which  depend  on  circumstances  which  we  can  neither  foresee  nor 
calculate  upon  :  these  anormal  arrangements,  whether  they  affect  the 
general  form  of  the  region,  or  belong  specially  to  one  of  its  elements, 
sometimes  produce  secondary  modifications  in  the  normal  relations;  but 
this  is  not  always  the  case.  The  organic  varieties  sometimes  consist 
in  an  increase  or  diminution  of  the  usual  arrangement;  sometimes 
they  cause  certain  analogies  between  different  regions  of  the  body,  or 
between  groups  of  animals  which  differ  in  their  position  in  the  animal 
scale :  finally,  sometimes  they  establish  great  analogies  between  the 
different  systems  of  the  same  organism,  particularly  between  the  dif- 
ferent orders  of  vessels,  or  between  these  and  the  nerves.  All  these 
varieties  are  important,  as  they  may  require  peculiar  precautions  in 
the  modes  of  operating. 

All  regions  which  are  naturally  bounded  have  evident  uses  :  some- 
times they  contribute,  as  in  the  limbs,  to  form  pillars  of  support : 
sometimes,  as  in  the  trunk,  they  circumscribe  great  splanchnic  cavi- 
ties. Some  regions  are  extremely  movable  :  others  are  fixed.  These 
remarks  on  topographical  physiology  are  highly  important  in  certain 
points  where  the  regions  are  always  more  or  less  modified  during 
their  action ;  they  show  in  every  part  the  relations  of  sympathy 
between  the  different  parts  of  the  body,  relations  of  which  an  idea  is 
easily  formed  by  considering  the  communications  of  the  nerves  and 
vessels. 

Finally,  when  a  region  has  been  studied,  it  becomes  easy  to  form  an 
idea  of  its  different  pathological  states ;  and  we  can  study  to  more 
advantage  surgical  operations  particularly,  which  are  intended  to 
restore  more  or  less  perfectly  the  normal  state,  by  acting  upon  the 
surface  of  a  part  or  upon  the  deep  organs.  Thus,  by  a  know- 
ledge of  the  action  of  each  of  the  muscles  of  a  region,  and  of  their 
combined  action,  and  considerations  peculiar  to  this,  we  can  explain 
the  different  displacements  in  fractures  of  its  skeleton  or  its  dislocations. 
By  the  arrangement  of  the  vessels  and  the  collateral  passages  in  a 


18  INTRODUCTION. 

region,  we  can  explain  the  re-establishment  of  the  circulation,  where 
the  principal  vascular  trunks  are  obliterated:  we  can  account  for 
certain  local  congestions  in  regions  which  are  not  irritated,  but  which 
are  situated  near  others  which  are,  as  redness  of  the  eye,  rumbling 
in  the  ear,  cerebral  irritation,  &c.  These  deductions,  besides  being 
useful  in  pathology  and  operative  medicine,  are  also  of  service  in 
engraving  firmly  upon  the  memory  the  most  minute  details  of  topo-. 
graphical  anatomy.  Farther,  the  importance  of  anatomy  generally, 
and  particularly  of  topographical  anatomy,  to  physicians  and  surgeons 
is  now  admitted,  and  it  is  unnecessary  to  urge  its  claims.  In  fact, 
without  an  intimate  knowledge  of  the  axilla,  who  would  dare  open  the 
simplest  abscesses,  or  use  a  cutting  instrument  in  this  part,  where  the 
slightest  error  might  be  fatal  ?  Who  would  presume  to  operate  for 
hernia,  to  tie  the  carotid  artery,  or  to  open  the  trachea,  if  he  were  not 
intimately  acquainted  with  the  regions  on  which  these  operations  are 
performed  ?  Is  it  not  topographical  anatomy  which  teaches  in  certain 
cerebral  inflammations  to  apply  leeches  behind  the  ears,  or  to  the 
pituitary  membrane,  or  to  the  upper  region  of  the  head,  &c.  ?  And  is 
it  not  an  intimate  acquaintance  with  the  costal  region,  which  teaches 
us  in  affections  of  the  pleura  to  apply  leeches,  blisters,  and  other 
similar  remedies  on  the  side  of  the  thorax,  over  the  digitations  of  the 
serratus  magnus  muscle  ;  and  that  if  used  on  the  arm,  the  same 
applications  will  be  much  more  powerful  if  employed  on  its  inner 
side? 


TABLE 

OF 

THE    REGIONS     OF    THE    HUMAN    B  O  D  Y\ 


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TOPOGRAPHICAL     ANATOMY. 


OF     THE     HUMAN     BODY. 

MAN,  placed  at  the  head  of  the  scale  of  human  beings,  possesses  all 
their  general  properties,  and  is  distinguished  from  them  by  peculiar 
characters,  particularly  by  his  intelligence ;  hence  the  immense"  ana 
logics  with  which  our  subject  abounds,  and  which  belong  to  the 
general  science  of  nature ;  hence  also  certain  differences,  which  it  is 
the  object  of  this  treatise  to  point  out. 

Man  is  alternately  in  a  state  of  rest  and  of  motion ;  in  a  state  of 
rest,  his  history  belongs  to  anatomy  ;  physiology  treats  of  him  only  in 
a  state  of  motion.  In  both  cases,  the  science  of  the  organization  is  the 
same,  and  the  complete  separation  of  these  two  states  would  be  almost 
impossible,  and  would  injure  the  advance  of  the  science.  The  phy- 
siological remarks  of  Bichat  upon  general  and  descriptive  anatomy, 
have  sufficiently  demonstrated  the  advantages  of  an  opposite  course 
in  regard  to  these  sciences,  and  it  would  be  very  erroneous  to  believe 
that  topographical  anatomy  was  an  exception.  In  fact,  every  region 
of  the  body  has  peculiar  uses,  which  are  perfectly  inseparable  from  it. 
This  kind  of  physiology,  which  may  be  called  topographical,  is  often 
blended  with  that  of  the  apparatus  of  organs  ;  but  again,  it  is  entirely 
distinguished  from  them ;  it  has  a  special  character,  and  must  be 
studied  separately.  These  physiologico-topographical  considerations 
are  highly  important  in  certain  regions,  which  are  considerably  modi- 
fied in  an  anatomical  point  of  view,  solely  by  the  action  of  the  organs. 

There  is  no  comparison  capable  of  demonstrating  exactly  the  form 
of  the  human  body :  roundness,  however,  is  one  of  its  characteristics. 
Generally  speaking,  the  height  of  the  body  is  between  five  and  six 
feet,  its  breadth  is  much  less.  The  centre  of  the  height  of  the  body 
always  falls  upon  the  pelvis ;  it  varies,  however,  in  the  two  sexes,  as 
we  shall  see  hereafter.  The  centre  of  its  breadth  is  marked  by  a  sort 


22  TOPOGRAPHICAL  ANATOMY. 

Of  raphe,  which  also  varies  very  much  ;  this  raphe  is  situated  on  the 
median  line,  or  rather  in  an  antero-posterior  median  plane,  which 
.divides  the  body  into  two  nearly  similar  halves ;  it  is  in  relation  to  this 
plane  that  the  human  body  is  represented  by  all  anatomists,  to  be  sym- 
metrical. This  symmetry,  however,  which  appears  in  the  adult  so 
perfect  in  masses,  becomes  much  less  so,  if  we  regard  it  in  detail ;  the 
regions  and  the  organs  which  compose  them,  will  furnish  us  constantly 
the  instances  of  this.  Bichat  has  said  too  much  in  favor  of  the  sym- 
metry of  the  organs  of  relation,  and  has  touched  too  lightly  on  that  of 
the  organs  of  nutrition.  The  two  kidneys  and  the  bladder  are  cer- 
tainly more  symmetrical  than  the  summit  of  the  cerebral  hemispheres 
and  the  vertebral  column  in  the  back.  Farther,  the  symmetry  varies 
very  much.  Authors,  and  particularly  Meckel,  speak  of  the  symmetry 
between  the  upper  and  lower  extremities ;  we  admit  that  there  is  an 
analogy  between  them,  but  there  is  no  similitude,  and  consequently 
no  symmetry. 

The  natural  direction  of  the  body  when  in  motion,  is  vertical ;  all 
the  sophisms  of  philosophers  to  show  that  we  were  born  to  be  quad- 
rupeds, are  refuted  by  anatomy,  which  constantly  proves  the  contrary. 
In  this  posture,  the  axis  of  the  body  or  the  true  median  line,  which, 
passing  through  the  centre  of  the  three  splanchnic  cavities,  should 
fall  between  the  feet  upon  the  ground,  forms  with  it  an  angle  of  ninety 
degrees.  In  a  state  of  absolute  rest,  the  body  could  not  preserve  this 
position  ;  it  proceeds  horizontally,  rests  on  the  back,  and  always 
inclines  to  the  right;  this  arrangement  is  produced  by  the  greater 
development  of  the  right  portions  of  the  body,  and  by  the  existence 
of  the  liver  on  this  side,  the  weight  of  which  is  only  compensated  in 
part,  by  that  of  the  spleen  on  the  left. 

Some  men  of  science,  deceived  by  the  remote  analogy  of  animals 
articulated  externally,  have  asserted  that  the  body  of  man  is  formed 
of  a  certain  number  of  super-imposed  and  more  or  less  similar  layers, 
some  of  which  are  extended  to  form  the  limbs.  This  truly  philoso- 
phical idea,  which  could  have  been  formed  only  by  those  who  possess 
a  minute  acquaintance  with  our  organization,  and  with  that  of  animals, 
must  be  mentioned  in  the  general  examination  of  the  body ;  but  as  it 
refers  particularly  to  the  trunk,  we  shall  avail  ourselves  of  it  on  that 
occasion.  The  human  body  has  for  a  base  the  skeleton,  upon  which 
its  general  form  depends ;  other  parts,  which  are  less  resisting,  are 
superadded,*  and  form  the  surfaces,  which  are  sometimes  strong  and 
vigorous,  and  sometimes  graceful  and  delicate.  The  body  of  man  is 

*  All  the  vertebfated  animals  present  the  same  arrangement :  their  skeleton  is  internal ; 
they  are  said  to  be  articulated  internally  ;  other  animals  have  a  skeleton  on  the  outside  of 
the  muscles  :  they  are  said  to  be  articulated  externally. 


OF   THE   HUMAN   BODY.  23 

developed  very  curiously;  it  passes  successively  through  a  certain 
number  of  phases,  each  of  which  represents  permanent  states  in  the 
scale  of  animals ;  thus,  for  instance,  although  at  first  a  zoophyte,  its, 
organization  afterwards  becomes  more  complex,  until  it  finally  acquires 
its  elevated  position  in  the  animal  scale. 

These  changes,  to  which  all  animals  are  subjected,  were  discovered 
long  since  in  some  of  them,  particularly  in  insects,  because  in  them 
they  take  place  slowly,  and  are  easily  observed.  In  man,  on  the 
contrary,  they  occur  so  rapidly  as  to  have  escaped  observation,  until 
recognized  by  the  labors  of  Meckel,  Tiedemann,  St.  Halaire,  Blainville, 
<fcc.  These  changes,  which  are  so  various  and  numerous  in  the  early 
periods  of  life,  are  repeated  after  birth,  and  produce  the  differences  of 
the  ages. 

When  conception  occurs,  our  body  is  entirely  fluid,  and  gradually 
assumes  its  density. 

These  changes  in  the  form  take  place  more  rapidly  than  in  the 
structure,  but  can  not  be  overlooked.  The  human  fetus  soon  tends 
to  assume  that  form  which  will  characterize  it  in  the  adult  state. 

In  the  early  periods  of  the  fetus,  when  its  analogy  with  other 
animals  is  greater,  the  greater  is  the  symmetry  between  the  sides  of  its 
body,  and  the  central  point  of  its  height  falls  on  a  point  which  is 
nearer  the  head. 

The  whole  organism  is  formed  like  the  elements,  of  separate  parts 
which  unite  more  or  less  rapidly ;  in  the  early  periods  of  fetal 
existence,  the  direction  of  the  body  is  that  of  a  regular  curve 
concave  anteriorly. 

The  human  body  presents  important  sexual  varieties.  The  male 
is  taller  and  heavier  than  the  female ;  in  the  former,  the  central  point 
of  the  body  falls  on  the  summit  of  the  symphysis  pubis ;  in  the  female, 
below  it.  The  male  is  broadest  at  the  shoulders,  the  female  at  the 
hips.  The  male  is  remarkable  for  strength  ;  the  female  is  more 
feeble,  and  is  distinguished  by  the  fineness  of  her  skin,  the  little  hair 
upon  it,  and  the  roundness  of  the  whole  body ;  the  genital  organs, 
however,  of  the  two  sexes,  present  differences  to  which  we  shall 
attend  hereafter. 

The  different  races  of  the  human  species,  also  present  to  the  ana- 
tomist the  subject  of  curious  remarks ;  their  characteristic  differences 
may  be  considered  as  modifications  of  the  type,  in  which  the  human 
organism  was  primitively  formed.  The  principal  races  are  four,  the 
Caucasian,  the  Mongolian,  the  Ethiopian,  and  the  American,  which 
is,  perhaps,  a  variety  of  the  second.  Their  general  anatomical 
differences  are  deduced  from  the  color  of  the  skin,  and  from  the 
proportion  of  the  parts.  We  %will  only  remark  that  the  Caucasian 


24  TOPOGRAPHICAL  ANATOMY. 

race  seems  to  be  formed  in  the  beauty  of  the  primitive  type;  the 
Mongolian  and  the  American  are  a  little  removed  from  this ;  while 
the  Ethiopian  or  negro  race,  differs  from  it  still  more. 

The  individual  varieties  are  very  numerous ;  they  refer  to  the 
height,  the  breadth,  the  more  or  less  vertical  direction,  and  to  the 
symmetry.  In  the  latter  respect,  the  principal  general  deviation  of  the 
human  body  consists  in  a  complete  transposition  of  the  lateral  organs, 
a  transposition  which  Beclard  has  seen  only  once  in  two  or  three 
thousand  individuals,  but  which  we  consider  to  be  less  rare ;  but  we 
cannot  state  any  definite  proportion.  We  have  deposited  in  the 
cabinet  of  the  faculty,  two  fetuses,  which  present  instances  of  it.  We 
have  shown  another  to  our  class  the  present  year,  and  have  also 
observed  this  anomaly  twice  in  the  dissecting  rooms. 

An  organization  which  is  so  complex  and  so  admirably  combined, 
and  which  is  subjected  to  laws  even  in  its  anomalies,  could  not  be 
conceived  without  a  continual  action  which  constitutes  life  ;*  this 
action  can  be  only  temporary,  since  the  organs  which  produce  it,  tend 
continually  to  change,  in  obedience"  to  the  law  of  their  evolutions. 
Human  life,  like  its  organs,  passes  through  a  certain  number  of 
changes.  The  embryo,  which  is  a  few  days  old,  lives  by  imbibing 
the  fluids  which  surround  it,  like  the  infusory  animals ;  at  a  later 
period,  the  vessels  of  the  placenta  are  developed,  and  probably  there 
is  an  absorption,  and  the  nutrition  is  more  complex ;  the  heart,  being 
annexed  to  the  vascular  system,  renders  the  circulation,  which  was 
before  simple  as  in  insects,  much  more  complicated ;  before  the 
pulmonary  artery  is  formed,  the  circulation  resembles  that  of  fishes  ; 
at  a  later  period  it  is  more  analogous  to  that  of  reptiles.  Respi- 
ration before  birth,  takes  place,  perhaps,  through  the  skin  ;t  but 
afterwards  it  occurs  by  the  lungs.  The  intellect  is  developed 
gradually  in  infancy,  and  the  nutritive  life  depends  upon  it;  at 
puberty,  a  third  order  of  functions  is  established,  the  genital,  which 
sometimes  govern  the  others ;  during  the  adult  or  mature  age,  man 
fulfils  three  orders  of  functions,  which  are  equally  developed ;  some 
have  for  their  end  his  own  preservation ;  the  others  the  perpetuation 
of  the  species  ;  at  a  later  period  the  genital  powers  are  lost,  the 
mental  faculties  are  enfeebled,  and  the  nutritive  life  alone  remains. 
In  following  this  progressive  evolution  of  the  functions,  we  see  that 

*  To  attempt  to  define  life  exactly,  would  be  to  undertake  a  thing  prematurely,  for  we 
ought  first  to  possess  all  the  elements  of  the  question,  and  the  science  is  far  from  this.  We 
consider  life  to  be  only  the  organization  in  action. 

t  At  least  the  thinness  of  the  skin,  'and  the  reapirable  gas  discovered  in  the  waters  of  the 
amnios  by  Lassigny,  may  lead  to  this  presumption*-bcsides,  Edwards,  by  the  finest  and  most 


conclusive  experiments,  has  proved  this  cutaneouJ^respiration  to  exist  in  the  batracia. 


n*-lu 
>u#>rc 


OF   THE  HUMAN  BODY.  25 

in  the  fetus,  the  organs  are  at  first  independent  in  their  action,  but 
afterwards  become  subordinate  to  each  other,  and  so  connected  that 
they  cannot  act  separately.  In  fact,  in  the  early  periods  of  life,  the 
vessels  are  sufficient  for  the  circulation  without  the  heart,  but  when 
the  heart  is  once  formed,  if  we  remove  it,  the  circulation  is  arrested. 

Such  is  man  during  his  existence,  and  when  his  system  is  regularly 
developed ;  but  this  is  not  always  the  case ;  sometimes  the  cause  of 
the  development  is  suddenly  arrested,  although  we  are  unable  to 
account  for  this  curious  phenomenon. 

Hence  the  changes  which  constitute  monstrosities ;  changes  which 
may  affect  parts  of  the  body,  or  the  whole  individual.  We  shall  con- 
sider them  here  in  this  latter  respect.  The  infinite  number  of  stages 
through  which  man  passes  to  arrive  at  the  perfect  state,  measures 
exactly  the  infinite  variety  of  these  general  monstrosities,  because  the 
irregular  formation  always  resembles  one  of  these  stages  ;*  instances 
are  not  wanting  in  support  of  this  ingenious  theory  of  monstrosities. 
Is  it  not  because  the  fetus  has  been  arrested  at  the  commencement  of 
its  development,  that  the  semi-organized  masses,  termed  moles,  are 
formed  in  the  uterus?  and  do  not  these  false  developments,  when 
arrested  at  a  later  period,  cause  acephalous  fetuses,  &c.,  and  leave  to 
certain  full  grown  fetuses  some  resemblance  with  the  lower  animals  ; 
giving  rise  to  those  trivial  but  remarkable  histories  that  women  have 
brought  forth  animals  ?  I  am  aware  that  certain  monstrosities  cannot 
be  explained  on  this  principle,  but  this  only  proves  that  many  causes 
concur  to  produce  these  deviations,  and  it  is  no  reason  why  the  theory 
should  be  rejected ;  in  the  present  state  of  the  science,  this  conduct 
would  be  absurd,  not  only  because  the  theory  of  arrested  development 
holds  true  with  most  cases>  but  also  because  it  is  connected  with  the 
known  laws  of  the  organism,  and  because  certain  monstrosities  could 
have  been  produced  in  no  other  manner.  In  other  cases,  the  normal 
formation  of  man  is  deranged  in  a  measure,  by  an  excess  of  deve- 
lopment, and  supernumerary  parts  are  formed,  or  the  parts  are 
Unusually  large. 

Such  are  the  general  causes  which  act  upon  the  organism  from 
its  beginning ;  but  in  order  to  have  a  complete  idea  of  these  changes, 
We  must  add,  that  female  monsters  are  much  more  numerous  than 
males ;  that  one  deviation  often  causes  another ;  hence,  Beclard 
has  asserted  that  the  absence  of  a  part  of  the  nervous  system  often 

*  Animals  are  subject  to  fewer  monstrosities  the  lower  they  are  in  the  scale  ;  because 
they  pass  through  fewer  stages  of  development,  and  because  the  deviations  of  their  organ- 
ism are  for  the  most  part  only  reproductions  of  those,  and  never  raise  the  animal  to  a  higher 
degree  of  the  organization.  In  fact,  a  monstrosity  of  the  bird  kind  never  presents  the 
voluminous  brain  of  a  mammal.  M 

4  r 


26  TOPOGRAPHICAL    ANATOMY. 

prevents  the  formation  of  nerves,  and  consequently  of  the  organs  influ- 
enced by  these  in  the  normal  state ;  the  effect,  however,  may  have 
been  taken  for  the  cause ;  this,  at  least,  would  seem  demonstrated  by 
the  cases  mentioned  by  Serres,  who  has  also  cited  others,  which  show 
that  the  nerves  and  their  centres  of  origin  are  more  independent  in 
their  formation  than  has  been  admitted.  The  absence  of  one  part 
consequently  causes  the  absence  of  the  corresponding  part  of  the  san- 
guineous system;  the  reverse  does  not  seem  to  be  true,  as  Serres 
asserts ;  for  the  vessels  arise  in  the  organs,  and  never  extend  to  form 
them.  Finally,  two  organisms  are  sometimes  more  or  less  perfectly 
united,  and  what  is  more  strange,  one  of  them  may  contain  the  other. 
Sometimes  these  anomalies  are  simple,  and  are  compatible  with  life ; 
in  other  cases,  they  are  complex,  some  of  the  essential  organs  are 
deficient,  and  the  infant  dies  at  birth. 

Our  organs,  when  completely  formed,  are  also  exposed  to  numerous 
diseases,  some  of  which  are  produced  by  physical  agents,  while  others 
result  from  a  greater  or  less  vital  derangement ;  sometimes  they  are 
slight,  in  other  cases  they  are  extremely  serious,  and  soon  destroy  life. 
Whatever  may  be  their  result,  they  are  marked  externally  by  appear- 
ances and  symptoms  which  are  modelled  by  the  structure  of  the 
body,  or  of  one  of  its  parts  if  the  alteration  be  local.  Hence  a  true 
pathological  physiology,  which  can  be  interpreted  properly  only  by 
anatomy,  while  at  the  same  time  it  directs  the  hand  of  the  physician, 
in  cases  where  an  operation  is  required  to  restore  the  equilibrium 
necessary  to  preserve  life. 

When  death  supervenes,  whether  it  results  slowly,  from  the  altera- 
tion of  the  organs  and  their  functions  consequent  on  old  age,  or  if  on 
the  contrary,  it  cuts  off  an  individual  in  the  prime  of  life,  by  an  acute 
disease,  all  the  vital  phenomena  do  not  completely  and  instantly  dis- 
appear ;  the  heart  contracts  for  a  long  time,  although  its  power  is  not 
sufficient  for  the  circulation;  the  nerves,  also,  and  particularly  the 
muscles,  retain  some  vitality  for  a  variable  length  of  time.  Nysten's 
experiments  have  proved  that  these  latter  may  contract  six  or  eight 
hours  after  the  respiration  and  circulation  have  ceased  ;  this  length  of 
time  varies,  however,  with  the  kind  of  death.  Finally,  the  muscles 
contract  for  the  last  time,  the  whole  system  becomes  rigid,  and 
continues  so  for  a  greater  or  less  length  of  time,  and  decomposition 
immediately  succeeds. 

The  body,  when  insensible,  preserves  a  certain  expression,  which 
depends  on  the  nature  of  the  death  and  the  sensations  which  have 
preceded  it ;  paleness  of  the  face  is  a  characteristic  of  individuals  who 
have  died  from  hemorrhage ;  in  apoplectics,  on  the  contrary,  the  face  is 
red  and  swelled,  and  the  features  of  those  in  whom  the  agony  of  death 


OP  THE  TRUNK.  27 

has  been  long  and  painful,  have  also  an  expression  of  deep  suffering. 
When  dissolution  takes  place,  these  characters  disappear,  but  new  and 
very  curious  phenomena  are  seen,  especially  when  fermentable 
matters  exist  in  the  stomach ;  the  face  and  the  eyes,  which  were 
collapsed,  tumefy ;  the  latter  become  brilliant,  and  start  from  their 
orbits ;  the  eyelids  open,  and  the  face  assumes  a  frightful  expression. 

Chaussier  attributes  this  change  to  the  disengagement  of  gas  in  the 
stomach,  by  which  the  diaphragm  is  crowded  up,  and  consequently 
the  blood  is  sent  to  the  upper  part  of  the  vascular  system.  Finally,  in 
a  very  short  time,  the  elements  of  the  body  are  separated,  obey  their 
affinities,  enter  into  new  combinations,  some  proceed  into  the  atmo- 
sphere, others  remain  combined  with  the  ground,  and  the  organism 
disappears. 

The  human  body  is  composed  of  the  trunk  and  extremities,  which 
have  a  distinct  structure  and  uses  ;  they  must  be  examined  in  detail. 


PART    I. 


OF     THE    TRUNK. 

• 

THE  trunk  is  the  splanchnic  portion  of  the  body.  In  our  species  its 
length  is  a  little  more  than  half  the  height  of  the  individual.  Its 
breadth  varies,  but  is  much  less  than  the  length.  The  thickness,  or 
the  antero-posterior  extent  is  still  less ;  hence  the  general  form  of  the 
trunk  is  flat. 

The  direction  of  the  trunk  may  be  seen  very  well  posteriorly ;  it  is 
undulating,  projects  anteriorly  at  its  two  extremities,  and  is  hol- 
lowed in  the  centre.  Its  size  also  varies;  it  bulges  above,  but  becomes 
smaller  at  the  neck ;  it  again  enlarges  at  the  thorax,  and  then  con- 
tracts slightly,  after  which  the  enlargement  of  the  pelvis  follows. 

The  first  section  of  each  limb  also  increases  the  transverse  measure 
and  the  size  of  the  trunk  by  resting  on  it,  as  we  shall  see  hereafter. 

Considered  externally,  the  trunk  presents  a  central  part  and  two 
extremities.  It  may  also  be  considered  according  to  its  four  faces ; 
the  anterior  or  sternal  is  flat,  and  more  hairy  than  the  others,  presents 
below  a  very  distinct  raphe,  but  none,  or  nearly  none,  above ;  the  limbs 
arise  from  the  lateral  faces,  and  are  nearly  blended  with  them ;  the 


28  TOPOGRAPHICAL   ANATOMY. 


posterior  or  spinal  face  is  marked  in  its  whole  extent,  and  on  the 
median  line  by  a  very  distinct  raphe,  situated  in  a  long  groove,  at  the 
base  of  which  we  perceive  the  series  of  the  spinous  processes  of  the 
vertebras,  while  on  the  sides  are  two  muscular  prominences  which  are 
more  distinct  below  than  above. 

We  learn  from  analogy,  and  from  examining  the  trunk  in  man, 
that  it  is  formed  of  a  certain  number  of  superimposed  layers  or  rings, 
which,  although  not  exactly  similar,  as  in  the  inferior  animals,  are 
remarkably  analogous ;  in  fact  each  of  these  segments  includes  a 
vertebra,  a  portion  of  the  cerebro-spinal  nervous  system,  a  pair  of 
nerves,  and  some  vessels  and  muscles  which  are  very  analogous. 

In  the  annelides,  for  instance,  this  analogy  is  so  great,  that  the 
description  of  one  of  the  sections  of  the  body  will  give  an  exact  idea 
of  the  whole  individual.  In  man,  however,  this  is  not  the  case  ;  the 
trunk  is  so  modified  anteriorly  and  on  the  sides  as  to  form  large 
cavities,  lined  by  serous  membranes,  in  which  the  viscera  are  situ- 
ated. The  rings,  however,  remain  so  apparent  posteriorly,  that  it  is 
convenient  to  examine  them  in  this  direction ;  ^attending,  however, 
only  to  their  analogies,  and  deferring  the  characteristic  differences 
of  the  regions  until  we  describe  them.  (See  the  posterior  cervical: 
the  dorsal,  the  lumbar,  and  the  sacral  regions.}  This  posterior  face 
of  the  trunk,  called  by  Beclard  the  great  spinal  region,  has  for  a 
skeleton  the  posterior  or  apophysary  portion  of  the  vertebrae  ;  the 
vertebral  canal  consequently  belongs  to  it,  and  also  the  vertebral 
grooves,  which  are  separated  from  each  other  by  the  spinous  pro- 
cesses ;  this  skeleton  protects  the  spinal  marrow,  which  does  not 
descend  entirely  to  the  bottom  in  the  adult  in  whom  it  seems  to  be 
contracted  from  below  upward  ;*  it  is  enveloped  by  three  membranes  ; 
the  external  is  very  dense  and  does  not  adhere  to  the  bones,  as  in  the 
skull ;  it  is  termed  the  dura  mater  ;  the  second,  the  internal,  covers 
the  organ  directly,  the  pia  mater  ;  the  last  is  intermediate,  is  the  true 
serous  membrane,  the  arachnoid;  the  sacrospinalis  muscle  is  also 
common  to  all  the  points  of  this  face  of  the  trunk ;  its  transverse  fasci- 
culi adhere  to  the  bones ;  the  other  muscles  are  superficial,  and  exist 
only  in  certain  parts,  and  will  be  examined  hereafter ;  the  vascular 
system  is  also  arranged  uniformly  in  every  part,  it  is  on  the  outside 
or  inside  of  the  vertebral  canal ;  on  the  outside,  the  lateral  arteries  of  the 
trunkt  send  into  the  vertebral  grooves  a  considerable  twig,  which  is 

*  This  arrangement  is  established  by  the  arrangement  in  the  fetus,  where  the  medulla  fills 
the  whole  vertebral  canal,  by  what  is  observed  in  all  the  vertebrated  animals  where  the  me- 
dulla descends  very 'low,  and  in  man  by  the  origin  of  the  last  pairs  of  nerves  from  the 
crural  portion  of  this  medulla. 

J  The  lumbar,  intercostal,  lateral  sacral,  and  the  twigs  of  the  vertebral  artery. 


OF    THE   TRUNK.  •  29 

distributed  to  the  muscles ;  these  same  external  trunks  send  inward, 
through  each  inter  vertebral  foramen,  another  twig  which  follows  the 
corresponding  nerve,- sends  a  filament  into  the  body  of  the  vertebra, 
and  another  to  the  membranes  of  the  spinal  marrow,  while,  pursuing 
its  course,  it  anastomoses  with  the  spinal  arteries,  which  are  distributed 
to  this  region.  Two  long  veins  descend  along  the  anterior  wall  of 
the  vertebra]  canal,  communicate  on  the  outside  with  the  lateral  veins 
of  the  trunk,  and  unite  with  the  internal  venous  rings,  which  are 
equal  in  number  to  the  vertebrae  ;  others  form  on  the  outside  a  net- 
work on  the  vertebras,  and  are  afterwards  united  near  the  interverte- 
bral  foramina,  with  the  preceding  veins.  The  lymphatic  system 
follows  the  direction  of  the  venous  ;  it  is  little  known  in  the  vertebral 
canal.  A  pair  of  nerves  formed  of  two  unequal  roots,*  one,  posterior, 
formed  of  the  filaments  of  sensation,  the  other,  the  anterior,  the  con- 
ductor of  motion,  emerges  from  the  canal  after  passing  obliquely,  but 
their  obliquity  and  extent  gradually  increase  from  above  downward  ; 
each  of  these  nerves  sends  behind  the  vertebra  into  the  muscles,  a 
filament  proportional  in  size  to  the  size  of  the  muscles,  but  identical 
in  arrangement  with  them.  Some  cellular  tissue  exists  within  and 
on  the  outside  of  the  vertebral  canal ;  the  first  is  more  loose  than  the 
second,  and  is  found  only  between  the  dura  mater  and  the  bony  walls 
of  the  vertebral  canal ;  where,  also,  the  adipose  vesicles  alone  occur. 
Finally,  we  remark  that  the  skin  is  considerably  thick  in  every  part 
where  it  is  depressed  by  the  adhesion  which  it  forms  with  the  summit 
of  the  spinous  processes  of  the  vertebra?. 

Development.  The  distinct  facts  which  have  been  collected  by  a 
great  many  distinguished  anatomists,  Meckel,  Tiedemann,  Beclard, 
Chaussier,  Blainville,  &c.,  on  the  development  of  most  of  the  organs 
and  regions  of  the  trunk,  allows  us  analytically  to  lay  down  the 
general  laws  of  the  normal  development  of  the  trunk.  It  is  first  seen 
on  the  umbilical  vesicle,  its  centre  or  abdominal  portion  being  formed 
before  its  extremities,  and  although  it  is  not  demonstrated  by  direct 


*  The  structure  of  these  veins  is  very  similar  to  that  of  the  others,  while  the  term  sinus, 
which  is  applied  to  them,  seems  to  render  the  idea  obscure. 

t  In  this  j-espect  anatomists  differ  very  much,  and  Beclard  states  that  the  posterior  root  is 
larger  than  the  anterior  in  the  neck,  while  the  opposite  is  true  in  the  lumbar  region.  Gall 
was  more  correct  in  saying  that  the  posterior  root  is  always  the  larger ;  it  was  important  to 
determine  this  point,  which  has  become  particularly  curious  since  the  experiments  of  Magen- 
die.  Our  researches  on  this  point  have  determined  that  the  posterior  root  is  to  the  anterior : 
in  the  neck, :  :  2  :  1 ;  in  the  back,  :  :  1  :  1  ;  in  the  sacrum  and  loins,  :  :  1  j  :  1,  which  agrees 
perfectly  with  our  knowledge  of  the  functions  of  the  parts  to  which  these  different  nerves  are 
distributed.  Some  experiments  of  Bouvier  support  the  experiments  of  Magendie,  showing 
the  plexiform  interlacing,  and  their  division  between  all  the  filaments  which  arise  from  the 
common  trunk ;  thus  anatomy  and  physiology  will  always  mutually  support  each  other. 


so  TOPOGRAPHICAL  ANATOMY. 

inspection,  it  would  seem  that  the  two  lateral  segments  are  at  first 
formed  in  its  whole  extent,  and  that  they  soon  unite,  not  at  their 
surface,  but  by  a  central  point,  placed  on  a  level  with  the  bodies  of 
the  vertebrae  ;  two  large  grooves  are  then  formed,  the  anterior,  which 
is  deeper,  and  the  posterior ;  these  are  the  rudiments  of  the  splanchnic 
cavity,  and  that  of  the  spine.  Next,  and  this  has  been  observed 
directly,  the  two  edges  of  these  open  cavities  increase,  meet  each 
other,  and  unite  by  a  raphe,  which  appears  first  above,  afterward 
below,  and  the  permanent  marks  of  which  would  prove  that  the 
progress  of  nature  is  such  as  we  have  described.  The  annular  form 
of  this  part  of  the  body  is  more  apparent  the  younger  the  fetus  is  ;  the 
spinal  marrow  descends  at  first  to  the  base  of  the  vertebral  canal,  and 
renders  its  different  segments  more  similar  ;  we  will  add  in  regard  to 
the  special  development  of  its  posterior  face,  that  the  spinal  marrow 
is  formed  at  first  of  two  distinct  cords,  which  soon  unite  in  one  layer, 
and  that  it  presents  a  posterior  groove,  which  closes  at  the  back 
part,  and  forms  a  central  canal,  and  is  afterwards  obliterated  by  the 
gray  substance ;  finally,  these  changes  take  place  at  the  upper  part 
more  quickly  than  at  the  lower. 

Varieties.  The  trunk  varies  very  much  according  to  the  ages  ;  in 
the  first  periods  of  life,  its  length  equals  that  of  the  whole  body ;  it 
increases  absolutely  until  the  age  of  twenty-five,  and  at  the  same  time, 
its  size,  compared  with  the  whole  frame,  gradually  diminishes;  in  the 
first  periods,  also,  the  antero-posterior  diameter  exceeds  the  transverse  ; 
the  direction  is  uniformly  that  of  a  curve  concave  anteriorly;  a  direc- 
tion which  reappears  in  the  old  man,  after  disappearing  through  half 
of  life.  The  different  enlargements  of  the  trunk,  and  the  contractions 
between  them  are  successively  formed. 

In  the  female,  the  length  of  the  trunk  is  proportionally  less  than  in 
the  male ;  in  the  former,  the  transverse  diameter  is  greatest  at  the 
pelvis,  in  the  latter  between  the  shoulders. 

All  or  nearly  all  the  individual  varieties  of  adult  age,  represent  only 
the  normal  state  of  other  periods  of  life,  or  that  of  a  different  sex. 

Uses.  The  trunk  forms  principally  cavities,  fitted  for  the  protec- 
tion of  those  viscera  which  are  most  necessary  for  individual  life  ; 
viscera  to  the  functions  of  which  it  contributes  something  by  its 
movements.  Slight  mutilations  of  this  part  by  operations  are  not 
admissible,  and  thus  many  of  its  diseases  are  mortal,  when  they  do 
not  yield  to  ordinary  remedies. 

Pathological  Deductions  and  Operations.  The  trunk  is  not 
always  formed  -  regularly  as  has  been  mentioned ;  sometimes  its  pro- 
gress is  arrested,  sometimes  it  exceeds  its  usual  bounds  ;  hence  occur 
fissures  or  abnormal  unions,  to  which  we  shall  attend  specially  here- 


OF    THE   TRUNK.  31 

after,  From  the  manner  in  which  the  trunk  is  formed,  its  extremities 
may  be  entirely  deficient,  while  its  centre  always  exists  ;  and  in  fact, 
the  development  of  the  individual,  and  his  existence,  even  when  muti- 
lated, supposes  this  point  of  the  trunk.  We  have  never  seen  a  complete 
fissure  of  the  whole  trunk ;  but  in  some  individuals  the  anterior 
cavities  are  open  on  the  median  line ;  the  same  thing  has  often  been 
seen  posteriorly  in  the  cavity  of  the  medulla,  the  vertebral  canal ; 
finally,  there  are  cases  of  fissure  of  the  bodies  of  the  vertebrae,  all  of 
which  deviations  of  formation  are  easily  explained  by  the  development 
of  the  fetus  being  arrested,  since  they  resemble  the  normal  states  of 
the  embryo.  As  the  formation  of  the  trunk  is  completed  above 
sooner  than  below,  abnormal  fissures  are  more  frequent  at  the  lower 
part;  hence  some  writers  have  erred  in  ascribing  as  the  cause  of 
its  usual  appearance  below,  and  of  spin  a  bifida,  the  position  of  the 
fetus  in  utero  during  the  early  periods  of  gestation,  which  position 
varies  very  much :  as  the  central  canal  of  the  medulla  exists  only 
at  an  early  period,  dropsical  accumulations  take  place  at  this  time 
within  this  organ,  while  at  a  later  period  the  serum  always  collects 
externally.  The  muscles  of  the  whole  trunk  sometimes  contract  in 
different  kinds  of  tetanus ;  the  posterior  in  opisthotonos,  the  anterior  in 
emprosthotonos,  the  lateral  on  one  side  in  pleurothotonos,  and  finally? 
all  together,  in  tonic  tetanus.  The  position  of  the  spinous  processes 
of  the  vertebree  directly  under  the  skin,  explains  the  frequency  of 
their  fractures  and  those  of  their  layers,  from  external  violence ;  the 
fractures,  however,  are  less  frequent,  because  the  processes  are  situated 
in  the  median  depression,  formed,  as  has  been  said,  in  individuals 
who  are  strong,  by  the  sacrospinalis  muscles.  As  the  spinal  nerves 
proceed  obliquely  to  a  greater  or  less  distance  before  leaving  their 
canal,  we  must  not,  if  we  wish  to  act  upon  their  origin,  in  partial 
paralyses,  employ  our  remedies  upon  a  point  of  the  region  directly  on 
a  level  with  the  paralyzed  part,  but  upon  a  higher  part. 

The  trunk  is  generally  divided  into   extremities,  and  a  central 
portion,  which  we  must  now  study. 


32  TOPOGRAPHICAL   ANATOMY, 


SECTION   I. 

EXTREMITIES    OP    THE  TRUNK. 

Of  the  two  extremities  of  the  trunk,  one  is  a  spheroid,  the  head ; 
the  other  is  rudimentary  in  man,  but  more  distinct  in  animals,  and 
forms  the  tail. 


CHAPTER     I. 


OF      THE      HEAD. 

The  head  is  the  cerebral  extremity  of  the  trunk.  It  is  situated 
horizontally  on  the  vertebral  column,  of  which  it  is  considered  by 
zootomists  as  an  expansion. 

The  absolute  size  of  the  head  is  considerable,  Its  external  face  is 
covered  with  skin  forward,  backward,  upward,  and  on  the  sides  ;  below, 
on  the  contrary,  it  has  no  relation  with  the  skin,  but  joins  the  neck 
with  which  it  is  blended ;  its  internal  face  forms  cavities,  which  protect 
the  upper  expansions  of  the  cerebrospinal  axis,  and  the  principal 
organs  of  the  senses. 

Development.  The  head  is  not  at  first  distinct  in  the  ovoid  mass  of 
the  very  young  embryo ;  afterward,  it  is  separated  from  the  rest  of  the 
trunk  by  a  circular  contraction  which  indicates  the  neck ;  if  We  except 
the  commencement  of  fetal  existence,  its  proportional  size  is  greater, 
the  younger  the  fetus  is ;  its  structure  then  is  not  perceptible ;  its  size 
depends  on  that  of  the  cranium,  as  the  face  is  very  small :  at  a  later 
period,  the  structure  of  the  face  is  more  advanced  than  that  of  the 
cranium ;  thus  at  these  two  different  periods,  the  size  and  develop- 
ment of  these  two  parts  have  opposite  relations.  The  protected  organs 
are  formed  first,  the  protecting  parts  afterward,  and  their  development 
is  always  secondary  to  that  of  the  former.  The  head  is  formed,  and 


OF   THE    CRANIUM.  33 

the  trunk  also,  of  lateral  parts  which  unite  on  the  median  line ;  the 
division  continues  longer  in  the  bones  than  in  the  soft  parts. 

Varieties.  The  head  presents  numerous  individual  varieties  of 
sexes  and  races,  which  are  mentioned  minutely  in  all  works  on 
descriptive  anatomy ;  we  will  only  state,  that  the  posterior  part  of  the 
head  in  the  female,  is  developed  much  more,  proportionally  speaking, 
than  in  the  male. 

Pathological  Deductions  and  Operations.  The  absence  of  the 
head  in  the  first  period  of  fetal  existence  explains  its  absence  in  certain 
full  grown  monsters  ;  this  defect  constitutes  acephalia,  which  must  be 
distinguished  from  anencephalia,  which  we  shall  mention  hereafter ; 
farther,  the  head  alone  may  be  deficient,  this  is  simply  acephalia ;  it 
may  be  absent  with  a  greater  or  less  portion  of  the  trunk,  as  we  shaH 
mention  hereafter.  Acephalia  is  attended  with  numerous  anomalies 
of  the  viscera  of  the  trunk,  because,  as  Beclard  states,  an  organ  is 
deficient  when  its  nerves  do  not  primitively  exist. 

The  head  is  one  of  the  most  important  parts,  and  although  the  fetus 
may  exist  without  it  while  within  the  uterus,  it  is  necessary  to  extra- 
uterine  life,  because  this  portion  of  the  trunk  contains  the  organs  which 
direct  the  contractions  necessary  for  respiration,  and  when  this  agent  is 
deficient,  respiration  cannot  take  place ;  the  removal  of  the  heacj  also 
causes  death,  because  it  removes  the  respiratory  principle. 

The  head  comprises  the  cranium  and  the  face;  parts  which  are 
distinct  in  every  respect. 


ARTICLE     I. 


OP     THE     CRANIUM. 

The  cranium  is  the  cerebral  portion  of  the  head ;  it  has  an  irregular 
oval  form,  the  great  extremity  of  which  is  posterior ;  it  is  situated  at 
the  upper  and  back  part  of  the  head,  and  forms  that  part  which  is 
directly  continuous  with  the  spine  ;  its  direction  is  horizontal  in  man, 
and  oblique  to  the  horizon  in  animals ;  its  absolute  size  varies  much  ; 
its  proportional  size  is  always  inversely  as  that  of  the  face. 

The  external  surface  of  the  skull  is  loose  and  covered  with  skin, 
upward,  forward,  backward,  and  on  the  sides  ;  below  it  is  blended  with 
the  neck  and  the  face.  Its  inner  surface  is  in  contact  with  the  nervous 

5 


34  TOPOGRAPHICAL  ANATOMY. 

system,  is  lined  with  the  parietal  fold  of  the  arachnoid  membrane,  and 
is  more  or  less  prolonged  by  septa. 

Structure.  The  cranium  is  formed  of  bone,  and  is  covered  with 
two  periostea,  the  external  of  which  is  thin,  while  the  internal  is  more 
developed  ;  the  soft  parts  are  situated  on  the  outside,  and  vary  much  ; 
they  give  rise  to  numerous  veins  termed  the  emissary,  which  have  a 
very  curious  arrangement,  of  which  practitioners  take  advantage  in 
treating  diseases  of  the  brain  or  of  its  membranes  j  these  vessels  have 
no  valves,  their  radices  are  situated  on  the  outside  of  the  skeleton  of  the 
cranium,  and  unite  in  trunks,  which  continually  increase ;  they  pass 
through  the  sutures  or  the  venous  foramina,  and  go  directly  into  the 
meningeal  sinuses,  into  the  meningeal,  or  the  diploic  veins.  The 
great  arterial  trunks,  which  are  distributed  in  the  cavity  of  the 
cranium,  send  twigs  to  the  outside,  towards  the  organs  of  the  senses, 
which  connect  the  circulation  of  the  latter  with  that  of  the 
cranium;  they  are  also  remarkable  for  their  broad  anastomoses. 

Development.  To  the  general  development  of  the  head,  we  must 
add,  when  speaking  of  the  cranium,  that  it  forms  first  at  its  base, 
that  its  arch  is  completed  the  last ;  the  fontanelles,  the  traces  of  this 
slow  formation,  continue  for  a  long  time.  The  numerous  varieties 
of  the  head,  which  have  been  mentioned  before,  are  manifested  particu- 
larly in  the  skull. 

Pathological  deductions  and  operations.  The  whole  of  the  skull 
is  sometimes  deficient :  this  deformity  is  termed  by  Becard  acrania  / 
sometimes  its  base  only  exists :  this  is  called  anencephalia ;  this 
monstrosity  was  for  a  long  time  confounded  with  acephalia,  but  it  is 
perfectly  distinct  and  causes  fewer  anomalies  in  the  internal  viscera. 
Most  authors  think,  that  anencephalia  is  produced  accidentally  by  a 
disease  which  destroys  the  mass  of  the  brain  during  fetal  existence, 
and  at  the  same  time  arrests,  or  prevents  the  development  of  the 
upper  parts  of  the  skull  after  the  base  was  formed.  Finally,  in  some 
cases,  the  arch  of  the  cranium  is  formed,  but  always  remains 
separated  to  a  greater  or  less  extent ;  hence  arise  hernia  of  the 
encephalon.  The  arrangement  of  the  emissary  veins  shows  the 
possibility  of  acting  powerfully  on  the  internal  parts,  and  particularly 
by  a  retrogade  motion  of  drawing  blood  directly  from  the  meningeal 
veins.  The  general  arrangement  of  the  arteries  accounts  for  external 
swellings,  and  for  the  affections  of  certain  organs  of  the  senses, 
in  internal  inflammations. 

Such  are  the  general  ideas  furnished  by  examining  the  cranial 
portion  of  the  hea'd ;  in  order  to  be  acquainted  with  it  more  minutely, 
we  must  examine  successively  the  parietes  of  its  cavity  and  its 
cavity. 


OCCIPITO-FRONTAL   REGION.  35 

PARAGRAPH     FIRST. 

PARIETES  OF  THE  CRANIUM. 

Anatomists  number  six  parietes  of  the  skull,  the  upper,  the  lower, 
the  two  lateral,  the  anterior,  and  the  posterior :  but  it  is  more  conve- 
nient for  the  study  of  this  part  of  the  skeleton,  to  divide  the  cranium 
into  an  arch,  (which  includes  the  upper,  the  anterior,  and  the  posterior 
parietes,)  and  into  the  lateral  and  inferior  parietes.  The  first  are  unat- 
tached ;  the  last  is  blended  with  the  face  and  the  neck,  and  we  shall 
also  see  its  relations  with  the  ocular,  olfactory,  zygomatic,  pharyngeal, 
and  nuchal  regions.  Farther,  the  following  table  will  give  an  idea  of 
this  division  of  the  parietes  of  the  cranium  into  two  regions. 


tion.  i 


Arch 1.  Occipito-frontal  region. 

3    \  Unattached  portion.  1  C  Forward 2.  Temporal  region. 

Lateral    <  In  the  centre 3.  Auricular  region. 

parietes.  (  Posteriorly. 4.  Mastoid  region  - 

Attached  portion.          Lower  wall 5.  Reg-ion  of  the  base  of  the  skull. 


ORDER      FIRST. 

ARCH    OF    THE   CRANIUM. 


The  arch  of  the  cranium  constitutes  a  very  simple  region,  the 
occipito-frontal,  which  is  formed  in  every  part  of  the  same  layers ; 
the  termination  of  the  hair  forward  is  not  a  sufficient  reason  for  form- 
ing a  frontal  region ;  it  is  still  less  convenient  to  form  a  parietal 
and  an  occipital  region ;  this  would  expose  to  frequent,  vexatious  and 
useless  repetitions. 

OCCIPITO-FRONTAL      REGION. 

This  unmated  and  symmetrical  region  extends  from  behind  forward, 
from  the  external  occipital  protuberance  and  a  line  drawn  from  this 
point  to  the  mastoid  processes,  to  the  nasal  protuberance  and  the  eye- 
brows ;  on  the  sides,  the  termination  of  the  hair  separates  it  posteriorly 
from  the  mastoid  and  auricular  regions,  while  it  is  distinguished  ante- 
riorly from  the  temporal  region  by  a  curved  line  which  exists  on  the 
bone,  but  is  not  seen  externally ;  one  extremity  of  this  curve  rests 
on  the  external  orbitar  process,  the  other  on  the  root  of  the  zygomatic 
process,  and  forms  a  semi-circumference,  the  diameter  of  which  is  repre- 
sented by  the  last  process.  These  limits  are  all  natural  and  are  easily 
determined.  This  region  has  the  form  of  an  arch;  it  is  sometimes 
termed  the  arch  of  the  cranium.  Its  thickness  varies  from  many  causes, 


36  TOPOGRAPHICAL    ANATOMY. 

which  will  be  mentioned ;  in  the  adult  its  mean  thickness  is  half  an 
inch.  The  occipito-frontal  region  presents  two  faces ;  one  is  cutaneous, 
the  other  serous  ;  the  first  is  convex,  and  covered  with  hairs  posteri- 
orly:  anteriorly,  on  the  contrary,  for  a  quarter  of  its  length  it  is  nearly 
smooth ;  these  hairs  cover  the  posterior  three  fourths  of  the  region ; 
their  directions  vary.  Posteriorly,  the  hairs  pass  beyond  this  region, 
and  advance  toward  the  neck ;  anteriorly,  they  suddenly  terminate  in 
a  variable  line,  which  determines  the  height  and  certain  forms  of  the 
forehead,  while  its  different  degrees  of  inclination  depend  on  the  skele- 
ton ;  this  line  is  sometimes  a  simple  curve  concave  anteriorly,  some- 
times it  presents  a  convexity,  and  two  semi-circles ;  an  arrangement 
generally  considered  as  the  most  beautiful.  Forward,  and  on  the  out- 
side, the  hairs  are  extended  on  the  temples,  but  on  the  outside  and 
backward,  they  terminate  in  a  curve  which  embraces  the  auricular  and 
mastoid  regions ;  between  them,  are  the  orifices  of  numerous  sebaceous 
follicles.  The  hairs  vary  very  much  in  number,  size,  and  direction  ; 
sometimes  they  are  very  straight,  sometimes  very  curly,  and  frizzled  ; 
this  latter  state  exists  in  the  greatest  degree  in  the  negro  ;  their  color 
varies  from  white  to  the  deepest  black ;  their  length  is  determined  by 
custom ;  in  a  state  of  primitive  nature,  however,  they  descend  to  the 
lower  part  of  the  trunk,  and  their  growth  then  ceases,  or  it  is  very  much 
retarded ;  on  the  contrary,  when  cut  before  this  time,  their  growth  is 
rapid,  and  very  thick.  The  smooth  part  of  this  region,  the  forehead, 
presents  the  frontal  protuberances,  and  a  depression  below. 

The  serous  or  cerebral  face  of  the  arch  is  smooth,  and  constantly 
moistened  with  serum ;  the  large  falx  of  the  dura  mater  arises  from 
it  in  the  centre,  and  the  tentorium  posteriorly,  on  a  line  drawn  between 
the  mastoid  processes  and  the  external  occipital  protuberance. 

Structure.  —  1.  Elements.  This  region  is  composed  of  but  few 
parts  ;  its  resistance  is  caused  by  a  skeleton  formed  by  the  upper  part 
of  the  frontal  and  nearly  all  the  surface  of  the  parietal  bones  ;  these 
parts  are  united  by  the  sagittal  sutures,  and  sometimes  by  the  median 
suture  of  the  frontal  bone,  the  occipito-parietal  or  the  lambdoidal,  and 
the  fronto-parietal  sutures.  This  arch  presents  the  parietal  foramina 
in  the  centre,  and  on  the  inside,  the  frontal  crest  anteriorly,  the  longi- 
tudinal groove,  posteriorly ;  its  thickness  varies  much,  according  to 
the  ages  ;  in  the  adult,  iui  mean  thickness  is  four  lines  ;  it  is  greater 
anteriorly,  on  the  median  line,  at  the  frontal  crest. 

The  external  and  internal  periostia  pass  over  the  sutures,  adhere  to 
them  and  strengthen  them  much.  The  external  periosteum,  the 
pericranium,  presents  nothing  remarkable ;  the  internal  periosteum, 
the  dura  mater,  is  extremely  strong,  and  contains  within  it  two 
sinuses,  the  upper  longitudinal  and  the  lateral ;  on  a  level  with 


OCCIPITO-FRONTAL  REGION.  37 

the  union  of  the  latter,  the  torcular  Herophyli :  this  latter  is  situ- 
ated on  the  external  and  occipital  protuberances ;  the  others  at  the 
base  of  the  imperfect  septa,  which  are  sent  from  the  inner  face  of  this 
region  into  the  cavity  of  the  skull,  one  consequently  on  the  median 
line,  the  other  between  the  mastoid  processes,  and  the  external  occipi- 
tal protuberance.  The  occipito-frontal  muscles,  and  their  aponeurosis 
occur  here  ;  this  latter  forms  a  complete  covering  for  the  head,  galea 
capitis,  which  it  follows  even  upon  the  temples,  and  which,  with  its 
muscles,  is  very  important  in  this  region.  The  cellular  tissue  is  very 
rare  and  dense  on  the  inside  of  the  bones ;  on  the  outside,  it  is 
lamellar  and  very  loose  below  the  occipito-frontalis  muscle,  while  the 
opposite  is  true  above  it.  Fat  occurs  only  in  the  latter  point,  and 
but  little  exists  there. 

The  arteries  of  this  region  are  anterior,  posterior,  or  lateral ;  some 
are  situated  on  the  outside  of  the  skeleton,  others  are  deep  seated ; 
among  the  first,  the  anterior  emerge  from  the  orbit,  and  are  given  off 
by  the  supraorbitar  and  frontal  branches  of  the  ophthalmic  artery, 
which  comes  from  a  cerebral  trunk ;  the  posterior  are  twigs  of  the 
occipital  artery,  which  also  emerges  from  the  nucha;  finally,  the 
lateral  are  given  off  by  the  two  branches  of  the  temporal  artery  and 
by  the  posterior  auricular  artery,  all  of  which  anastomose.  Among 
the  second,  the  anterior,  the  anterior  meningeal  belong  to  the 
ethmoidal  arteries ;  the  posterior  to  the  occipital,  the  inferior  pharyn- 
geal,  and  the  vertebral  artery ;  they  are  called  the  posterior  menin- 
geal arteries ;  the  lateral  to  the  middle  meningeal  artery.  The 
veins  generally  follow  the  course  of  the  arteries,  except  the  frontal 
vein,  which,  however,  to  a  certain  extent  represents  the  course  of  the 
frontal  branch  of  the  ophthalmic  artery ;  it  is  rather  large,  and  it  is 
often  very  visible  externally ;  small  emissary  veins  are  situated  at  the 
sutures,  particularly  two,  which  are  large  at  the  parietal  foramina,  on 
the  top  of  the  region.  The  internal  lymphatic  vessels  are  not 
known ;  Mascagni,  however,  states  that  he  has  seen  some  in  the 
dura  mater ;  those  which  arise  externally,  form  two  very  large  lateral 
fasciculi,  which  follow  the  temporal  and  posterior  auricular  arteries, 
and  go  to  the  parotid  and  mastoid  ganglions ;  a  posterior  fasciculus 
follows  the  occipital  artery  and  goes  to  the  substernomastoid  gan- 
glions ;  finally,  a  small  anterior  fasciculus  accompanies  the  frontal 
vein,  descends  to  the  face,  and  goes  to  the  submaxillary  ganglions. 

The  nerves  are  anterior,  posterior,  and  lateral,  like  the  vessels  ; 
the  first  leave  the  orbit,  and  are  the  twigs  of  the  supraorbitar  nerve  ; 
the  second  come  from  the  nucha  and  are  the  posterior  branches  of  the 
first  cervical  nerves ;  finally,  the  last  are  filaments  of  the  facial  nerve, 


38  TOPOGRAPHICAL  ANATOMY. 

of  thesuper  ficial  temporal,of  the  inferior  maxillary,  and  of  the  mastoid 
nerve  of  the  cervical  plexus. 

Finally,  the  skin  and  the  parietal  fold  of  the  arachnoid  membrane 
complete  all  the  elements  of  this  part. 

2.  Relations.  The  relations  of  the  occipito-frontal  region  are 
extremely  simple ;  the  layers  are  uniform  in  every  part ;  the  first  is 
formed  by  the  skin,  which  is  dense  and  presents  numerous  follicles ; 
the  second  layer  is  composed  of  a  very  dense  cellulo-fatty  tissue,  form- 
ing bands  which  intimately  connect  the  skin  with  the  subjacent  layer  ; 
in  the  centre  are  all  the  external  vessels  and  nerves ;  the  third  layer 
is  formed  by  the  occipito-frontal  muscles,  and  the  epicranial  aponeu- 
rosis.  A  very  loose  lamellar  tissue  forms  the  fourth,  and  unites  the 
preceding  to  an  external  periosteum,  which  adheres  very  firmly  to 
the  sutures  and  the  parietal  foramina,  by  means  of  the  emissary  veins 
and  fibrous  prolongations  which  come  from  the  dura  mater  ;  next, 
the  bones  form  a  firm,  distinct,  and  solid  layer,  which  is  thickest 
anteriorly  on  the  median  line,  where  the  internal  frontal  crest  exists. 
Below,  the  internal  periosteum  presents  itself,  the  dura  mater,  the 
adhesion  of  which  varies  with  the  age,  and  is  always  firmest  at  the 
sutures  and  at  the  parietal  foramina ;  it  contains  in  the  places 
mentioned,  the  superior  longitudinal  sinus,  the  torcular  Herophyli, 
and  the  lateral  sinuses  ;  the  parietal  fold  of  the  arachnoid  membrane 
adheres  to  it  very  firmly,  and  terminates  the  region  on  the  inside. 

Development.  In  its  development  the  arch  of  the  cranium  presents 
four  distinct  periods,  which  are  observed  in  the  bones  better  than 
in  the  soft  parts.  1.  The  region  is  completely  separated  on  the 
median  line ;  2.  Next  the  soft  parts  unite,  the  bones  still  preserving 
marks  of  their  primitive  separation,  the  median  fontanelles  ;  the  ante- 
rior of  these  is  quadrilateral,  the  posterior  is  triangular,  both  are 
important  in  obstetrics  ;  3.  In  two  years  the  fontanelles  disappear,  the 
sutures  are  all  perfectly  formed,  and  the  arch  of  the  cranium  is  less 
liable  to  be  injured  by  external  violence  ;  4.  In  old  people  the  sutures 
disappear,  the  emissary  veins  which  pass  through  them  are  effaced 
and  change  into  fibrous  filaments,  the  parietes  of  bone  become  thinner, 
uniformly  in  every  part,  or  in  certain  points,  and  generally  near  the 
parietal  bones ;  this  diminution,  termed  senile  atropkia,  depends  on 
the  absorption  of  the  diploe,  and  sometimes  exists  to  such  a  degree, 
that  the  cranium  is  perforated ;  in  this  case  the  skull  is  always  very 
weak,  the  external  table  constantly  approaches  the  internal,  which 
remains  moulded  on  the  cerebrum.  In  the  fetus  and  the  young  child, 
the  external  'periosteum  is  separated  from  the  bones  by  a  thin  layer  of 
cartilage  for  their  increase  in  thickness,  and  adheres  very  slightly, 
while  the  dura  mater  is  attached  firmly ;  in  the  adult,  and  particularly 


OCCIPITO-FRONTAL   REGION.  39 

the  old  man,  the  dura  mater,  on  the  contrary,  adheres  slightly  and  the 
periosteum  firmly.  As  age  advances,  the  frontal  sinuses  sometimes 
extend  into  every  part  of  the  forehead. 

Varieties.  The  arch  of  the  cranium  presents  numerous  varieties  ; 
they  always  depend  on  the  bones,  which  are  moulded  on  the  encepha- 
lon ;  when  the  latter  is  very  much  developed  anteriorly,  the  region  is 
very  convex  in  this  direction.  This  development,  which  generally 
marks  the  Caucasian  race,  varies  however  very  much,  and  is  usually 
connected  with  great  intellectual  faculties ;  on  the  contrary,  a  large 
transverse  diameter  and  a  considerable  prominence  posteriorly,  a  deve- 
lopment caused  by  the  size  of  the  brain  in  this  part,  is  considered  by 
some  physiologists,  particularly  Gall,  as  indicating  a  great  develop- 
ment of  the  genital  powers.  This  region  sometimes  rises  very  high, 
as  in  conical  heads. 

Pathological  Deductions  and  Operations.  The  entire  absence  of 
this  region,  or  its  rudimentary  state  with  a  broad  median  separation, 
characterizes  an  encephalia;  when  it  is  partially  cleft,  it  exposes,  as  we 
have  already  seen,  to  hernias  of  the  encephalon,  which  sometimes 
supervene  accidentally  after  fractures  of  the  bones  with  loss  of  sub- 
stance, or  after  senile  atrophia,  which  has  left  a  broad  perforation ; 
these  hernias  form  tumors  which  are  remarkable  for  their  pulsation  and 
for  the  drowsiness  caused  by  their  compression.  The  ancients  attri- 
buted the  severity  of  wounds  in  this  region  to  the  lesion  of  the  cranial 
aponeurosis,  entertaining  the  false  idea  that  this  white  part  is  nervous ; 
these  wounds,  wherever  they  may  be,  are  serious ;  first,  because  some 
nerves  are  affected  very  near  the  centre  of  the  nervous  system, 
toward  which  the  pains  proceed :  second,  because  they  often  cause  an 
inflammation  which  extends  by  the  continuity  of  the  vessels  to  the 
meninges :  third,  because  the  frontal  vessels  arise  from  trunks  which 
are  also  distributed  to  the  brain,  and  although  the  irritation  caused  by 
these  wounds  solicits  the  blood  into  their  external  branches,  the  circu- 
lation in  the  internal  branches  is  quickened  by  the  same  cause,  and 
disposes  to  cerebral  affections  :  fourth,  finally,  besides  the  shock  which 
is  often  communicated  to  the  encephalon  in  these  cases,  fractures  and 
internal  effusions  may  supervene,  and  require  serious  operations. 

The  physical  injuries  of  the  arch  of  the  cranium  consist  in  more 
or  less  complicated  wounds  ;  they  may  occur  without  wounds  :  in  the 
first  case,  a  severe  pain  sometimes  results  from  the  partial  section  of  a 
nervous  filament ;  it  disappears  when  the  filament  is  completely 
divided :  hemorrhage  is  never  a  severe  symptom ;  the  arteries,  how- 
ever, situated  in  a  very  dense  tissue,  are  difiicult  to  tie;  we  have 
experienced  this  after  extirpating  an  erectile  tumor,  developed  upon 
the  posterior  part  of  this  region,  an  operation  which  we  performed  last 


40  TOPOGRAPHICAL  ANATOMY. 

year  with  great  success.  In  wounds  of  the  integuments,  the  occipito- 
frontalis  muscle  is  often  completely  separated  from  the  pericranium, 
as  we  may  readily  conceive  from  the  looseness  of  the  cellular  tissue 
which  unites  these  two  parts.  The  pericranium  also  may  be  sepa- 
rated, and  the  bones  be  fractured  with  or  without  depression ;  if  the 
wounding  instruments  proceed  farther,  the  two  meninges  may  be 
affected,  as  also  the  upper  parts  of  the  brain,  which  are  protected  by 
this  region.  The  fractures  of  the  skull  do  not  necessarily  agree  in 
place  with  the  lacerations  of  the  soft  parts ;  farther,  a  blow  upon  this 
region  does  not  necessarily  fracture  its  skeleton ;  from  the  known 
mechanism  of  the  cranium,  this  blow  may  affect  the  part,  near  the 
base  of  this  cavity,  and  fractures  at  a  greater  or  less  distance  from-it, 
may  supervene.  Fractures  are  generally  attended  with  the  separation 
of  the  two  periostea,  and  with  effusions  which  vary  in  their  situations, 
as  we  shall  see  hereafter ;  farther,  it  is  important  to  remember  the 
direction  of  the  sutures,  in  order  not  to  confound  them  with  a  simple 
crack.  When  the  frontal  sinuses  are  very  much  developed,  and 
extend  into  this  region,  their  anterior  wall,  if  depressed,  may  resemble 
a  very  serious  fracture.  When  this  region  is  injured,  effusions  of 
blood  often  supervene ;  they  may  be  external  or  internal ;  when 
external,  they  are  generally  situated  between  the  skin  and  the  occipito- 
frontalis  muscle,  and  are  very  slight,  on  account  of  the  density  of  the 
cellular  tissue,  which  does  not  allow  them  to  extend  far  :  the  position 
of  the  vessels  under  the  skin  in  the  cellular  tissue,  explains  the  situa- 
tion of  these  collections ;  sometimes,  but  rarely,  we  find  a  little  blood 
under  the  occipito-frontal  aponeurosis ;  it  is  infiltrated  to  a  distance, 
and  never  forms  a  tumor ;  when  these  effusions  are  internal,  they 
most  generally  occur  between  the  bones  and  the  internal  periosteum 
which  is  separated,  and  are  then  confined  to  this  place  of  separation ; 
they  result  most  commonly  from  the  lesion  of  the  emissary  veins,*  but 
they  may  also  exist  in  another  part,  which  is  generally  but  little 
known ;  they  sometimes  form  between  the  dura  mater  and  the  parietal 
fold  of  the  arachnoid  membrane,  which  in  this  place  are  intimately 
connected ;  Rostan  relates  an  instance  of  it  in  his  excellent  work  on 
the  softening  of  the  brain  ;  and  at  the  hospice  Bicetre,  we  examined 
a  deranged  person,  who  presented  one  at  the  parietal  fossa  of  the  right 
side.  It  existed  between  the  separated  dura  mater,  and  the  arachnoid 
membranes :  we  were  told  that  this  effusion  supervened  after  the 
unfortunate  battle  of  Waterloo,  in  which  this  man,  a  soldier  in  a 
regiment  of  the  line,  received  a  violent  sabre  blow  on  the  head  in  the 

*  We  examined  with  Cambournac,  an  individual  who  had  died  in  consequence  of  an 
effusion,  where  the  blood  came  from  the  middle  meningeal  artery,  which  was  injured  by  a 
spicula  of  bone. 


OCCIPITO-FRONTAL    REGION.  41 

point  corresponding  to  the  effusion  :  this  old  injury  was  perceived  at 
the  examination  by  a  broad  cicatrix  existing  on  the  soft  parts  and 
in  the  bones  which  had  been  injured.  The  effusions  are  always 
confined  within  very  exact  limits  ;  finally,  others  may  occur  more 
deeply  in  the  skull ;  we  shall  speak  of  them  hereafter.  Of  the  effusions 
of  blood  in  the  region  of  the  arch  of  the  cranium,  those  which  are 
formed  between  the  bones  and  the  dura  mater,  or  between  the  dura 
mater  and  the  parietal  arachnoid  membrane,  may  rationally  require 
trepanning  ;  because,  as  we  have  seen,  they  are  circumscribed,  which 
may  be  recognized  by  a  very  distinct  paralysis  of  one  side  of  the  body. 
When  the  injuries  of  the  arch  do  not  destroy  the  patient  immediately, 
they  often  cause  collections  of  pus,  some  of  which  are  external,  others 
internal ;  the  first  are  circumscribed  and  slight,  and  appear  between 
the  skin  and  the  epicranial  aponeurosis ;  or  they  are  formed  under 
this  latter,  and  are  then  diffuse  and  very  serious,  and  must  be  evacu- 
ated early ;  the  second  are  always  circumscribed ;  they  occur  on  the 
outer  surface  of  the  dura  mater,  and  are  frequently  fatal.  Caries,  and 
necrosis  of  the  skeleton  of  this  region  are  not  rare,  being  caused  par- 
ticularly by  syphilis,  which  also  gives  rise  to  exostoses ;  necrosis 
supervenes  only  when  the  disease  acts  on  the  pericranium ;  the  whole 
thickness  of  the  bone  is  then  separated  at  the  same  time,  and  it  is 
curious  that  it  is  never  reproduced ;  the  dura  mater  does  not  take 
the  place  of  the  internal  periosteum,  except  to  a  certain  extent 
and  it  differs  from  the  periosteum  of  other  places  in  not  repro- 
ducing a  new  bone ;  the  reason  of  this  is,  that  it  sends,  in  fact,  few 
vessels  into  the  bones,  which  are  nourished  principally  by  the  pericra- 
nium. Encysted  tumors  often  appear  in  this  region ;  these  are  real 
follicles,  developed  after  the  obliteration  of  their  neck ;  these  tumors 
are  flattened  on  account  of  the  firmness  of  the  skin,  and  are  always 
situated  on  the  outside  of  the  epicranium ;  they  are  easily  extirpated 
when  recent;  but  if  old,  this  is  not  the  case,  because  they  adhere 
firmly  to  the  deep  layers.  Inflammation  of  the  skin  is  very  painful, 
because  its  internal  adhesions  prevent  its  yielding;  it  is  generally 
followed  with  the  loss  of  the  hair.  This  inflammation  is  sometimes  of 
the  nature  of  erysipelas,  and  sometimes  affects  the  follicles  or  the 
bulbs  of  the  hair,  and  forms  the  mucous  exudations  of  children,  and 
the  different  kinds  of  tenia  :  in  all  these  diseases  there  is  an  engorge- 
ment of  the  anterior,  posterior,  or  lateral  lymphatic  ganglions,  in  fact 
of  those  to  which  the  lymphatic  vessels  from  the  diseased  part  go.  A 
peculiar  affection  of  the  papillae  of  the  hairs,  causes  a  singular  mat- 
ting of  the  hairs,  marked  in  plica  polonica,  in  which  disease  the  hairs 
are  said  to  become  vascular,  and  to  bleed  when  they  are  divided, 
The  fact  is,  that  the  blood  does  not  come  from  the  hairs  themselves, 


42  TOPOGRAPHICAL    ANATOMY. 

but  from  their  papillae,  which  are  elevated  above  the  level  of  the  skin, 
from  the  infundibuliform  cavity  of  the  root  of  the  hair,  in  the  same 
manner  as  blood  flows  from  the  papilla  of  the  plumes  of  the  young 
bird,  when  they  are  divided  near  the  skin,  and  not  from  the  plumes 
themselves.  This  region  is  the  place  selected  for  trepanning,  which 
should  not  be  performed  upon  the  sutures,  in  order  to  avoid  the  emis- 
sary veins  which  pass  through  them ;  nor  on  the  median  line,  to  avoid 
the  superior  longitudinal  sinus,  the  frontal  crest,  &c.  This  advice  is 
very  good,  but  should  not  be  followed  too  strictly,  for  these  accidents 
can  be  avoided.  We  have  already  mentioned  the  convenience  of  this 
operation  in  some  cases  ;  we  shall  return  to  the  subject  hereafter : 
trepanning  is  most  indicated  in  cases  of  fracture  with  depression 
when  symptoms  of  the  compression  of  the  brain  appear. 


ORDER     SECOND. 

LATERAL    WALL    OF    THE    CRANIUM. 


This  wall  is  formed  by  three  small,  simple,  and  distinct  regions ;  the 
temporal,  the  auricular,  and  the  mastoid  regions. 

1.      TEMPORAL      REGION. 

This  region  forms  the  anterior  portion  of  the  lateral  wall  of  the 
cranium ;  it  is  bounded  forward  by  the  external  orbitar  process  of  the 
frontal  bone ;  backward  by  the  root  of  the  zygomatic  process,  and  by 
the  auditory  passage ;  downward  by  the  zygomatic  arch ;  and  upward 
by  a  curved  line  concave  downward,  called  the  temporal,  which  line 
has  already  been  mentioned,  when  speaking  of  the  preceding  region. 

The  temple  is  flattened  transversely,  and  its  plane  is  nearly  perpen- 
dicular ;  it  is  thicker  than  the  occipito-frontal  region,  but  its  thickness 
varies  in  different  parts  ;  it  is  stronger  below  than  above,  and  anteriorly 
than  posteriorly ;  its  mean  thickness  anteriorly,  directly  above  the 
zygomatic  arch,  is  twelve  lines ;  posteriorly,  it  is  only  six. 

The  temple  presents  two  faces,  one  cutaneous,  the  other  serous ;  the 
first  is  covered  posteriorly  with  hair,  but  anteriorly,  it  is  continuous 
wilh  the  forehead,  and  increases  its  transverse  extent ;  its  lower  part 
is  convex  in  children,  but  in  the  adult,  on  the  contrary,  it  presents  a 
slight  depression,  which  marks  the  zygomatic  arch,  and  which  is 
deeper  the  thinner  the  individual  is  j  the  serous  face  presents  nothing 
remarkable ;  it  is  smooth,  moist,  and  rests  on  the  cerebrum. 

Structure.  —  1.  Elements.  The  elements  of  the  temple  are  few  ;  it 
owes  its  principle  resistance  to  a  skeleton  formed  of  the  squamous  part 
of  the  temporal  bone,  of  portions  of  the  parietal,  of  the  frontal,  of  the 


TEMPORAL  REGION.  43 

great  wing  of  the  sphenoid,  and  of  the  malar  bone  ;  these  pieces  are 
united  by  the  squamous,  the  spheno-temporal,  the  spheno-parietal,  and 
the  sphenoidal  sutures,  and  by  those  which  join  the  rnalar  bone  to  the 
frontal  and  sphenoid  bones,  and  to  the  zygomatic  process.  This  osseous 
surface  is  thin  and  transparent  above ;  on  the  inside,  it  forms  in  the 
adult  for  the  middle  meningeal  artery  an  osseous  canal,  which  is 
situated  as  high  as  the  external  orbitar  process,  and  two  fingers' 
breadth  behind  it ;  on  the  whole,  the  skeleton  of  the  temple  is  thinner 
than  that  of  the  preceding  region,  its  external  and  internal  periostea 
adhere  to  it  more  firmly,  because  there  are  here  more  sutures  which 
are  united  to  each  other  by  fibrous  bands  and  emissary  veins ;  the 
temporalis  muscle  fills  the  whole  temple  from  its  upper  to  its  lower 
boundary,  we  also  find  there  some  fibres  of  the  attrahens  aurem  and 
the  attollens  aurem  muscle.  The  occipito-frontal  aponeurosis  is 
extended  to  it,  and  there  forms  a  superficial  fascia ;  a  very  strong 
fibrous  layer  covers  the  temporalis  muscle,  and  concurs  with  the  tem- 
poral bones  to  form  a  channel  which  opens  downward  only ;  this  layer 
is  attached  to  the  whole  circumference  of  the  temple,  and  is  free  from 
adhesions  on  the  outside ;  on  the  inside,  on  the  contrary,  it  serves  for 
the  insertion  of  the  external  fibres  of  the  muscle ;  it  is  single  above, 
and  separated  below  into  two  layers,  which  embrace  the  zygomatic 
arch,  and  terminate  on  its  external  and  internal  faces,  leaving  between 
them  above  a  narrow  triangular  space ;  the  two  opposite  faces  of  the 
region  are  covered,  one  by  a  very  follicular  and  partially  hairy  skin, 
the  other  by  a  portion  of  the  parietal  arachnoid  membrane.  The 
internal  cellular  tissue  is  very  dense,  as  in  the  preceding  region ;  the 
external  is  not  abundant,  it  is  dense  especially  under  the  skin.  It  is 
rarely  found  in  the  subcutaneous  tissue  ;  it  constantly  exists,  however, 
between  the  two  layers  of  the  temporal  aponeurosis,  and  more  deeply, 
on  the  inside  and  in  front  of  the  temporalis  muscle. 

The  arteries  of  the  temple  are  situated  on  the  outside  or  inside  of 
the  skeleton ;  the  internal  are  given  off  by  the  trunk  of  the  middle 
meningeal  artery,  which  is  situated  in  the  osseous  canal  mentioned 
above  ;  the  first,  on  the  contrary,  are  superficial,  middle,  and  deep ;  the 
superficial  are,  the  trunk  of  the  temporal  artery  and  its  two  branches 
at  their  origin ;  the  middle  are  given  off  by  the  preceding  trunk,  and 
are  situated  between  the  two  layers  of  the  temporal  aponeurosis ;  the 
two  deep  arteries  are  branches  of  the  internal  maxillary;  all  these 
arteries  anastomose  together,  and  the  deep  arteries  communicate 
directly  with  the  orbitar  arteries,  by  twigs  which  pass  through  the 
malar  foramina  ;  this  connection  between  the  arterial  system  of  these 
two  points  of  the  body  deserves  to  be  noticed ;  it  has  often  been  impli- 
cated in  diseases  of  the  orbit.  The  veins  follow  strictly  the  course  of 


44  TOPOGRAPHICAL  ANATOMY. 

the  arteries,  except  the  numerous  emissary  veins  which  pass  through 
the  sutures. 

Some  of  the  lymphatic  vessels  proceed  superficially,  others  deeply, 
into  the  parotid  ganglions ;  a  great  number  come  from  the  occipito- 
frontal  region. 

The  nerves  are  superficial  or  deep ;  the  first  are  given  off  by  the 
facial  nerve,  and  the  auricular  filament  of  the  inferior  maxillary 
nerve ;  the  second  are  also  branches  of  this  last. 

2.  Relations.  The  relations  of  the  temple  are  very  simple ;  the  first 
layer  of  it  is  cutaneous,  as  in  almost  every  other  part ;  the  second  is  form- 
ed by  cellulo-fatty  tissue,  in  which  the  nerves  and  superficial  vessels 
of  the  region  are  situated,  We  remark  that  the  trunk  of  the  temporal 
artery  divides  there,  fifteen  lines  above  the  zygomatic  arch,  that  it  is 
situated  four  lines  from  the  auditory  passage,  and  that  on  leaving  this 
division,  its  anterior  branch  curves  forward  toward  the  forehead,  the 
posterior  backward  to  the  nucha.  The  third  layer  is  formed  by  the 
attollens  aurem  muscle  and  the  occipito-frontal  aponeurosis,  to  which 
it  adheres.  A  very  loose  cellular  tissue  separates  this  layer  from  the 
following,  constituted  by  the  temporal  aponeurosis,  forming  below 
by  its  two  layers  a  triangular  space,  in  which  an  adipose  button  of 
variable  size  and  the  middle  temporal  artery  are  situated.  The  tern- 
poralis  muscle  forms  a  deeper  layer  in  which  is  also  found  a  mass  of 
fat,  and  which  contains  in  its  thickness  near  the  bones,  the  deep  tem- 
poral vessels  and  nerves.  Finally,  when  all  these  parts  are  removed, 
the  pericranium  is  exposed,  and  its  adhesion  may  be  demonstrated  at 
the  sutures.  The  bones  then  appear,  and  under  them  the  middle 
meningeal  artery  in  the  position  already  mentioned,  the  dura  mater, 
and  then  the  arachnoid  membrane,  which  is  intimately  united  to  the 
former, 

Development.  The  resistance  of  the  temple  is  at  least  as  great 
as  that  of  the  occipito-frontal  region  ;  the  thick  layer  of  the  soft  parts 
which  cover  it,  more  than  compensates  for  the  thinness  of  its  ske- 
leton ;  this  resistance  and  this  thinness,  however,  are  by  no  means  the 
same  at  all  periods  of  life  ;  in  the  fetus  and  even  six  months  after 
birth,  the  bones  are  not  completely  united ;  but  a  membranous  space 
exists  between  them  anteriorly,  which  is  termed  the  anterior  and 
lateral  fontenelle.  After  birth,  this  region  bulges  much  from  two 
causes ;  first  from  the  fat,  especially  that  situated  between  the  two 
layers  of  the  aponeurosis,  second  from  the  slight  prominence  of  the 
zygomatic  arch. 

Varieties.  The  temple  varies  much,  presenting  a  very  marked 
depression  or  convexity,  according  to  the  degree  of  emaciation  or  the 
quantity  of  fat ;  these  varieties  are  caused  also  by  the  wasting  or 


TEMPORAL  REGION.  45 

development  of  the  fat    situated  between   the   two   layers   of    the 
temporal  aponeurosis. 

Pathological  and  Operative  Deductions.  Wounds  of  the  tempo- 
ral region,  even  if  not  very  deep,  may  be  attended  with  a  profuse 
hemorrhage,  especially  when  they  are  situated  near  the  auditory 
passage ;  this  accident,  however,  is  by  no  means  serious,  and  the 
temporal  artery  which  is  wounded  in  this  case,  is  easily  tied ;  con- 
tused wounds  or  simple  contusions  are  attended  with  effusions  of 
blood  under  the  skin,  between  the  two  layers  of  the  temporal  aponeu- 
rosis, and  on  the  bones,  against  which  the  deep  temporal  branches  are 
ruptured ;  the  centre  of  the  bone  is  protected  from  fractures  by  its 
deep  situation  and  by  the  temporalis  muscle ;  its  circumference,  on 
the  contrary,  formed  by  the  orbitar  process  and  the  zygomatic  arch,  is 
situated  superficially  and  projects  very  much ;  it  is  thus  naturally 
exposed  to  violence  and  is  often  fractured ;  the  base  of  the  temple, 
however,  is  sometimes  broken,  notwithstanding  its  advantageous 
situation;  these  fractures  are  generally  produced  by  counterblows, 
the  orbitar  arch  having  been  alone  affected.  In  these  cases,  circum- 
scribed effusions  often  form  between  the  dura  mater  and  the  bones ; 
we  have  already  mentioned  one  case  where  the  middle  meningeal 
artery  was  wounded  by  a  spicula  from  their  internal  table.  Fun- 
gous tumors  of  the  dura  mater  appear  here  more  frequently  than 
in  any  other  point  excepting  the  preceding  region.  Encysted  tumors 
containing  hairs  which  are  inserted  on  the  parietes  of  the  cyst  are 
often  developed  at  the  anterior  part  of  this  region  near  the  eyebrows  ; 
they  are  formed  by  the  development  of  follicles,  and  the  hairs  which 
are  found  in  them  belong  to  the  eyebrows,  from  whence  they  have 
deviated.  We  have  seen  the  whole  temple  raised  by  a  fungous 
tumor,  which  leaving  the  maxillary  sinus,  passed  through  the 
zygomatic  fossa  and  came  to  the  temporal  region.  The  operation  of 
trepanning  should  never  be  performed  upon  this  region,  unless  it  is 
absolutely  necessary;  the  thickness  of  the  external  soft  parts  is  a 
sufficient  reason  for  this  precept.  It  has  been  advised  also  not  to 
perform  the  operation  anteriorly  lest  the  middle  meningeal  artery 
contained  in  its  bony  canal  be  injured ;  our  remarks  show  at  what 
part  this  accident  can  happen;  in  an  urgent  case,  we  may  trepan 
even  on  this  point,  certain  that  the  hemorrhage  may  be  arrested  by 
introducing  a  piece  of  cork  through  the  hole  in  the  bone  ;  in  order  to 
preserve  those  fibres  of  the  temporalis  muscle  which  converge  down- 
ward, it  has  been  advised  in  trepanning  on  the  temple,  to  make  the 
external  incision  in  the  form  of  a  V,  so  as  to  obtain  a  triangular  fold, 
the  base  of  which  is  uppermost,  and  which  should  be  dissected  so  that 
only  the  point  adhered ;  this  advice  is  good.  Leeches  and  moxas 


46  TOPOGRAPHICAL  ANATOMY. 

may  be  placed  with  advantage  on  this  region  in  diseases  of  the  eye 
or  of  its  appendages  ;  the  nervous  and  particularly  the  vascular  com- 
munication which  we  have  demonstrated  between  these  two  points, 
confirms  the  propriety  of  this  choice.  Moxas  should  not  be  placed 
near  the  ear  for  fear  of  wounding  the  trunk  of  the  temporal 
artery,  which  happened  in  one  case,  where  hemorrhage  supervened, 
which  could  not  be  arrested  except  by  tying  the  vessel  above  and 
below  the  wound. 


2-     AURICULAR      REGION. 

The  external  portion  of  the  organ  of  hearing  is  situated  in  the  lateral 
wall  of  the  cranium,  and  the  internal  in  the  lower  wall ;  they  form  a 
region  which  is  very  complex  and  very  important.  It  is  minutely 
described  in  works  on  descriptive  anatomy ;  hence  we  shall  refer  to 
them  for  the  details,  and  shall  merely  review  the  most  important  points, 
and  state  the  most  prominent  pathological  changes  and  operations. 

The  auricular  region  is  formed  by  nature  for  a  physiological 
purpose,  and  is  composed  of  three  parts,  an  external,  the  true  acoustic 
trumpet,  a  middle  portion,  which  is  designed  to  insulate  on  the  inside 
a  membrane,  the  vibrations  of  which,  rendered  weaker  or  stronger  by 
a  special  apparatus,  are  intended  to  make  an  impression  on  a  tense 
band  situated  in  the  tortuous  cavities  of  which  the  last  part  is  formed. 

The  external  ear  is  composed  of  the  pinna  and  of  the  auditory 
passage ;  the  latter  particularly,  is  bounded  above  by  the  temporal 
region,  forward  by  the  parotid  region,  and  backward  and  downward 
by  the  mastoid  region,  from  which  it  is  separated  by  the  mastoido- 
auricular  fissure. 

Passing  over  the  depressions  and  prominences  which  exist  in  every 
part,  the  pinna  is  formed  by  a  fine  skin,  which  is  hairy  in  some  parts, 
and  has  numerous  follicles ;  it  is  united  by  a  very  dense  cellular  tissue 
to  the  membranous  cartilage  which  forms  the  skeleton  of  this  part, 
and  presents  grooves  filled  with  fibrous  tissue.  The  special  muscles 
of  the  pinna  are  so  rudimentary  in  man,  that  they  are  unimportant, 
especially  in  topographical  anatomy. 

The  auditory  passage  is  from  ten  to  twelve  lines  long  :  it  is  directed 
inward  and  forward,  and  is  curved  so  that  its  axis  is  convex  upward  ; 
it  is  broader  at  its  extremities  than  in  its  centre  ;  its  perpendicular 
diameter  is  more  extensive  than  the  transverse,  and  commencing  at 
the  bottom  of  the  concha,  terminates  suddenly  inward  by  a  septum, 
which  separates,  it  from  the  cavity  of  the  tympanum ;  this  septum  is 
formed  by  three  parts  ;  by  skin  on  the  outside,  by  the  mucous  mem- 
brane of  the  tympanum  on  the  inside,  and  in  the  centre  by  the  mem- 


AURICULAR  REGION.  47 

brane  of  the  tympanum  on  which  the  handle  of  the  malleus  rests 
posteriorly,  forming  one  of  its  upper  expansions.  This  septum  is 
oblique  downward  and  inward,  so  as  to  increase  the  length  of  the 
lower  wall  of  the  auditory  passage ;  it  sometimes  presents  an  opening 
caused  by  an  accidental  injury,  which  establishes  a  communication 
between  the  auditory  passage  and  the  cavity.*  The  inner  half  of  this 
passage  has  an  osseous  base  ;  the  outer  half  is  cartilaginous  and 
membranous;  it  is  cartilaginous  and  more  resisting  forward  and 
downward,  membranous  and  feeble  upward  and  backward :  its  carti- 
lage is  continuous  with  the  tragus,  and  presents  two  or  three  grooves, 
called  the  grooves  of  Santorini,  which  are  filled  with  ligamentous 
tissue.  The  upper  and  posterior  membane  is  fibrous,  and  unites  the 
two  edges  of  the  cartilage ;  a  prolongation  of  the  skin  of  the  concha 
lines  the  whole  passage,  forming  a  cul-de-sac  on  the  membrane  of  the 
tympanum ;  this  skin  is  fine,  and  very  follicular  on  the  outside,  and  is 
united  to  the  skeleton  by  a  very  dense  cellular  tissue,  and  contains 
at  the  upper  part,  near  the  base  of  the  passage,  the  laxator  tympani 
muscle. 

The  vessels  and  the  nerves  of  the  external  ear  are  capillary ;  they 
are  not,  consequently,  of  much  importance ;  some  are  anterior  and 
others  posterior.  The  anterior  arteries  arise  from  the  temporal  artery, 
the  posterior  from  the  posterior  auricular  artery ;  the  veins  attend  the 
arteries ;  the  anterior  lymphatics  go  to  the  parotid  ganglions,  the  pos- 
terior to  the  mastoid ;  the  anterior  nerves  are  given  off  by  the  super- 
ficial temporal  filament  of  the  inferior  maxillary  nerve,  and  the 
auricular  nerve  of  the  cervical  plexus :  the  posterior  by  the  mastoid 
nerve  of  the  same  plexus,  and  the  auricular  branch  of  the  facial 
nerve. 

The  middle  ear,  or  the  cavity  of  the  tympanum,  is  situated  between 
the  auditory  passage  and  the  internal  ear :  it  is  separated  from  the 
former  by  the  triple  septum  mentioned  above,  and  from  the  second,  by 
a  wall  of  bone,  on  which  it  rests  ;  the  fenestra  ovalis,  the  promontory, 
the  fenestra  rotunda,  and  its  canal,  are  well  described  by  Ribes,  who 
has  proved  that  the  membrane  of  the  fenestra  rotunda  mentioned  by 
authors,  is  situated  on  the  tympanum  higher  than  they  state,  and 
leaves  exposed  on  the  side  of  the  cavity,  the  end  of  the  spiral  septum 


*  We  do  not  mean  to  say  that  the  membrane  of  the  tympanum  does  not  present  an 
opening,  as  Rivinus  and  Scarpa  assert.  We  have  ascertained  that  one  exists  constantly  at 
the  upper  part,  formed  by  the  edge  of  the  membrane  and  the  frame  in  which  it  is  inserted : 
it  gives  passage  to  the  tendon  of  the  laxator  tympani  muscle.  This  anatomical  fact  is  gene- 
rally badly  understood,  because  the  terms,  membrane  of  the  tympanum,  and  septum  of  the 
base  of  the  auditory  passage,  are  confounded.  But  this  opening  does  not  establish  a  com- 
munication between  the  auditory  passage  and  the  cavity  of  the  tympanum. 


48  TOPOGRAPHICAL    ANATOMY. 

of  the  cochlea,  in  the  point  where  this  is  inclined  downward,  to  form 
the  lower  wall  of  the  vestibule;*  upward,  the  middle  ear  corresponds  to 
the  region  of  the  base  of  the  cranium,  and  receives  through  a  fissure 
some  arterial  filaments  from  the  dura  mater ;  below,  it  also  presents 
openings  for  the  nerves  and  vessels  ;  posteriorly,  it  corresponds  to  the 
cellules  of  the  mastoid  region,  which  presents  there  a  common  open- 
ing, situated  above  the  aqueduct  of  Fallopius,  of  the  pyramid,  and  of 
the  foramen,  through  which  the  cord  of  the  tympanum  emerges. 
Anteriorly,  the  cavity  is  continuous  with  the  pharynx,  by  means  of 
the  Eustachian  tube,  which  slopes  at  its  two  extremities ;  it  is  osseous, 
in  the  side  of  the  cavity,  and  cartilagino-membranous  inward,  while  its 
direction  is  oblique  forward,  downward,  and  inward,  from  the  tympa- 
num toward  the  pharynx ;  it  establishes  the  communication  between 
the  mucous  membranes.  Above  this  passage  is  a  groove,  through 
which  the  tensor  tympani  muscle  passes,  and  the  fissure  of  Glaser, 
through  which  pass  to  the  outside  the  cord  of  the  tympanum  and  the 
tendon  of  the  laxator  tympani  major  muscle.  Farther,  the  middle  ear 
is  traversed  from  without  inward,  by  a  chain  formed  of  four  little 
bones,  the  malleus,  the  incus,  the  os  orbiculare,  and  the  stapes,  which 
chain  unites  the  membrane  of  the  tympanum  and  the  fenestra  ovalis ; 
it  is  perforated  from  behind  forward,  by  the  superior  filament  of 
the  vidian  nerve,  which  is  adapted  to  the  malleus  and  to  the  mem- 
brane of  the  tympanum  in  its  upper  half,  and  finally,  it  is  covered  by 
a  very  fine  fibre-mucous  membrane,  which  is  continuous  with  that  of 
the  throat,  and  with  the  mastoid  cellules. 

The  internal  ear  is  situated  between  the  middle  and  internal  audi- 
tory passage ;  it  is  composed  of  the  vestibule,  the  cochlea,  and  the 
semi-circular  canals ;  the  vestibule,  besides  its  communication  with  the 
internal  auditory  passage,  presents  the  opening  of  the  fenestra  ovalis, 
that  of  the  vestibular  portion  of  the  cochlea,  the  five  openings  which 
terminate  the  semi-circular  canals,  and  that  of  the  aqueducts  of  the 
vestibule :  it  is  a  central  cavity,  the  lower  wall  of  which  looks  forward 
and  outward,  according  to  the  remarks  of  Ribes,  it  is  formed  by  an 
osseo-membranous  prolongation  of  the  septum  of  the  cochlea,  the 
prolongation  which  is  seen  at  the  base  of  the  canal  of  the  fenestra 
rotunda.  The  cochlea  is  situated  forward,  and  is  disposed  so  as  to 
measure  by  its  horizontal  axis,  the  distance  between  the  base  of  the 
auditory  passage  and  the  carotid  canal :  it  is  composed  of  two  slopes 
which  communicate  superiorly ;  one,  termed  that  of  the  tympanum, 

*  It  follows  from  these  curious  researches,  that  the  cavity  of  the  vestibule  may  receive  the 
vibrations  of  the  membrane  of  the  tympanum  through  the  fenestra  rotunda  and  its  canal : 
this  arrangement  shows,  also,  that  the  membranous  part  of  the  septum  of  the  cochlea  may 
be  made  to  vibrate  directly  by  the  oscillations  of  the  membrane  of  the  tympanum. 


AURICULAR    REGION.  49 

and  terminates  in  the  canal  of  the  fenestra  rotunda,  from  which  it  is 
separated  by  a  membrane  similar  to  the  tympanum,  -a  membrane  near 
which  commences  the  aqueduct  of  the  cochlea  ;  the  other,  the  vesti- 
bular,  is  shorter,  and  terminates  in  the  vestibule ;  they  are  separated 
by  a  septum,  which  is  osseo-fibrous  at  the  base,  but  membranous  only 
at  the  summit.  Farther,  this  septum  describes  two  and  a  half  spiral 
turns  around  the  axis,  near  which  it  is  bony;  and  this  axis  is  grooved 
with  a  cavity  dilated  outward  into  the  form  of  a  tunnel.  The  three 
semi-circular  canals,  which  are  placed  posteriorly,  open  into  the  vesti- 
bule by  five  foramina ;  one  only  is  common  to  the  two  vertical  canals ; 
the  anterior  opening  of  the  horizontal  canal,  and  the  separate  open- 
ings of  the  vertebral  passages,  are  dilated.  The  whole  internal  ear  is 
lined  with  a  very  fine  and  very  vascular  periosteum ;  the  vestibule, 
particularly,  contains  two  small  sacs,  one  of  them  is  spherical  and 
distinct,  the  other  is  larger  and  common,  and  receives  the  extremities 
of  tubes  placed  in  the  semi-circular  canals,  which  are  dilated  in  places 
where  their  skeleton  is  enlarged.  The  membrane  of  the  vestibule 
penetrates  the  cochlea  in  the'  same  manner.  All  these  cavities 
contain  nervous  expansions,  which  float  in  the  liquid  of  Cotugno,  and 
are  surrounded  by  some  bubbles  of  air,  as  Ribes  has  demonstrated ; 
this  arrangement  allows  the  membranes  of  the  internal  ear  to  vibrate, 
without  injuring  the  nervous  pulp.  The  internal  ear  is  connected 
by  its  circulation  with  the  cerebrum,  and  its  principal  artery  comes 
from  the  basilar. 

Development.  The  development  of  the  auricular  region  is 
indicated  by  numerous  changes  in  its  different  portions ;  first,  there  is 
no  external  ear,  the  tympanum  looks  downward,  and  is  even  with  the 
head,  as  in  many  animals ;  the  pinna  next  appears,  but  it  is  perfectly 
flat ;  in  two  months,  its  depressions  and  prominences,  which  .are  so 
distinct  in  the  'adult,  begin  to  appear.  At  a  later  period,  the  short 
auditory  passage  is  entirely  membranous,  and  the  tympanum  is  very 
oblique ;  the  latter  soon  rises,  and  the  ossification  of  the  passage  com- 
mences at  the  cavity  of  this  tympanum.  It  is  not,  properly  speaking, 
until  after  birth,  that  the  bony  part  .of  the  auditory  passage  extends  a 
little  ;  at  twenty-five  years  it  equals  the  membrano-cartilagih'ous  part, 
and  afterward  exceeds  it  in  length. 

The  middle  ear  is  at  first  very  small ;  it  does  not  extend  into  the 
mastoid  region ;  the  Eustachian  tube  is  entirely  membrano-cartila- 
ginous.  After  birth,  the  osseous  part  enlarges  at  the  expense  of  the 
first,  but  is  never  equal  to  it:  the  little  bones  are  formed  at  the  third 
month  ;  a  little  earlier  than  this,  the  ossification  of  the  tympanum  has 
commenced  around  the.  fenestra  rotunda,  which  first  looks  outward, 
then  is  directed  backward,  after  the  promontory  is  formed,  and  is 

7 


50  TOPOGRAPHICAL    ANATOMY. 

again  directed  outward,  when  the  mastoid  process  is  developed :  this 
part,  also,  is  filled  until  birth  with  a  whitish  mucus. 

The  internal  ear  is  at  first  only  membranous,  then  cartilaginous 
before  the  third  month  of  fetal  existence,  at  which  period  ossification 
commences ;  farther,  the  whole  ear  obeys  this  general  law  of  develop- 
ment, that  the  protecting  parts  appear  after  those  which  are  to  be 
protected. 

Pathological  deductions  and  operations.  The  ear  presents  nume- 
rous anomalies,  such  as  the  flattening  of  the  pinna,  or  the  very  great 
prominence  of  some  of  its  eminences,  the  absence  of  the  lobule  or  its 
adhesion  with  the  skin,  the  shortness,  narrowness,  and  obliteration  of 
the  auditory  passage.  The  membrane  of  the  tympanum  is  very 
oblique,  and  is  directed  downward  in  monsters  which  have  no  face ; 
we  have  seen  two  external  auditory  passages  terminate  there.  The 
little  bones  of  the  ear  are  sometimes  perfectly  similar  to  those  of  ani- 
mals ;  the  labyrinth  remains  partly  membranous,  or  it  is  formed  of  a 
single  cavity.  In  an  individual  who  was  deaf  from  birth,  we  have 
found  the  auditory  nerve  wasted  and  reduced  to  a  simple  filament,  an 
osseous  concretion  existing  in  the  labyrinth.  The  ancients  considered 
injuries  of  the  pinna  to  be  extremely  serious,  deceived  by  the  false 
idea  that  its  cartilage  was  very  sensible  ;  some  have  spoken  of  its  frac- 
tures ;  its  elasticity  shows  that  simple  wounds  by  cutting  instruments 
have  been  considered  as  such ;  the  small  encysted  tumors,  which  are 
here  very  common,  are  most  generally  follicles  morbidly  developed  ; 
the  inflammation  of  the  external  ear  is  painful  in  a  direct  ratio  with 
the  adhesion  of  the  skin  with  the  subjacent  parts ;  hence,  when  -the 
skin  of  the  auditory  passage  is  inflamed,  severe  pain  exists.  The 
removal  of  the  external  ear  in  a  wound  of  the  head  affects  the  hear- 
ing, but  does  not  prevent  it  entirely;  but  we  must  not  conclude 
because  some  are  accustomed  to  hear  without  it,  that  the  external  ear 
is  useless.  The  lobe  of  the  ear  is  sometimes  perforated,  for  the  inser- 
tion of  ear-rings ;  this  operation  is  neither  painful  nor  dangerous,  as 
the  nerves  and  the  vessels  which  go  to  this  part  are  few  and  small. 

The  curve  of  the  auditory  passage  explains  the  necessity  of  draw- 
ing the  external  ear  upward  when  we  wish  to  examine  it ;  in  this 
manner  we  remove  this  curve,  which  does  not  exist  in  the  osseous 
portion.  When  instruments  are  introduced  into  the  auditory  passage, 
to  extract  foreign  bodies,  if  the  instrument  has  only  one  blade,  it 
should  be  carried  upon  the  lower  part,  as  we  can  introduce  it  in  this 
direction  more  deeply,  before  arriving  at  its  internal  limits,  as  this 
part  is  longer  :  If  they  have  two  blades,  one  should  be  introduced 
below  and  the  other  above  ;  as  the  vertical  diameter  of  the  passage  is 
more  extensive  than  the  transverse,  the  foreign  body  being  less  pressed 


AURICULAR  REGION.  "' .  *J 

upon  in  the  latter  direction,  leaves  a  greater  space  for  the  instruments, 
which  must  pass  inward  and  embrace  it.  Farther,  these  foreign 
bodies  cause  inflammation,  suppuration  of  the  passage,  and  sometimes 
the  destruction  of  the  tympano-auricular  septum,  inflammation  of  the 
tympanum,  and  by  the  continuity  of  the  vessels,  that  of  the  cerebral 
membranes,  of  which  Sabatier  relates  a  remarkable  case.  The  pus 
which  often  comes  from  the  auditory  passage,  may  be  furnished  by  its 
proper  membrane,  may  come  from  the  tympanum,  or  from  the  mastoid 
region  ;  the  membranous  structure  of  the  auditory  passage  at  its 
posterior  part,  explains  this  termination  of  the  mastoid  abscesses ; 
abscesses  of  the  parotid  region  sometimes  point  in  this  place,  destroy- 
ing the  fibrous  tissue  of  the  grooves  of  Santorini.  The  very  fine,  and 
almost  mucous  skin  of  the  auditory  passage,  often  gives  origin  to  real 
polypi ;  sometimes,  however,  the  polypi  which  occur  in  this  place, 
come  from  the  cavity  of  the  tympanum. 

The  tympano-auricular  septum  is  sometimes  broken  by  a  loud 
noise,  as  is  very  common  in  cannoniers  ;  Ribes  has  ascertained  that 
this  perforation  may  also  be  produced  by  the  pressure  of  the  hardened 
wax,  and  also  by  that  of  the  handle  of  the  malleus.  Farther,  it  is 
made  artificially,  to  allow  the  introduction  of  air  into  the  cavity  of  the 
tympanum,  when  it  cannot  enter  in  any  other  manner,  as  when  the 
Eustachian  tube  is  obliterated.  In  this  operation,  substituted  by  Sir 
Astley  Cooper  for  the  perforation  of  the  mastoid  process,  which  latter 
seems  to  us  more  rational,  as  we  shall  show  hereafter,  the  lower 
part  of  the  tympanum  should  be  perforated,  in  order  to  avoid  the 
handle  of  the  malleus  and  the  nerve  termed  the  cord  of  the  tympa- 
num, which  are  placed  at  the  upper  part.  As  the  septum  of  the 
tympanum  is  oblique,  when  we  wish  to  perforate  it,  we  must  employ  a 
trocar,  the  canula  of  which  has  a  fluted  extremity.  In  violent  blows 
on  the  head,  the  blood  which  flows  into  the  cavity  of  the  tympanum, 
and  oozes  through  the  Eustachian  tubes  or  the  auditory  passage,  after 
breaking  the  tympanum,  comes,  according  to  Beclard,  from  the  rup- 
ture of  the  emissary  vessels,  which  pass  from  the  dura  mater  into  the 
cavity,  through  the  upper  openings.  The  continuity  of  the  mucous 
membrane  of  the  throat  with  the  middle  ear,  explains  the  obliteration 
of  the  Eustachian  tube  and  lesions  of  the  ear,  in  chronic  affections  of 
the  throat.  We  shall  speak  of  introducing  an  instrument  into  the 
Eustachian  tube  hereafter.  The  severe  pains  of  internal  otitis  are 
easily  explained  by  the  resistance  of  the  parietes  of  the  tympanum, 
which  prevent  the  inflammatory  swelling,  and  consequently  cause  a 
compression.  The  rumblings,  and  other  affections  of  th^  internal  ear, 
which  are  so  common  in  diseases  of  the  brain,  are  easily  explained  by 
the  connection  in  the  circulation  of  the  brain  and  this  region,  which 


5-2  TOPOGRAPHICAL   ANATOMY. 

has  been  mentioned.  This  important  part  of  the  ear  is  doubtless 
often  affected ;  but  our  knowledge  upon  this  point .  is  so  slight,  that 
anatomy  does  not,  as  yet,  give  any  positive  explanation  of  most  of  the 
species  of  deafness  which  are  there  situated. 


3.      MASTOID     REGION. 

The  posterior  portion  of  the  lateral  wall  of  the  skull,  the  mastoid 
region,  has  very  distinct  limits ;  the  mastoido-auricular  fissure  for- 
ward ;  the  curved  line  marked  by  the  termination  of  the  hair,  back- 
ward and  upward  ;  and  the  point  of  the  mastoid  process  downward  ; 
it  is  very  thick,  and  is  not  very  extensive,  but  is  nevertheless  very 
simple  and  important.  The  mastoid  region,  like  all  those  which  con- 
tribute to  form  the  parietes  of  the  cranium,  or  any  other  cavity, 
presents  two  regions.  One  is  covered  with  skin,  and  is  convex  and 
rough,  the  other,  which  is  serous,  smooth  and  moist,  is  continuous 
with  the  side  of  the  tentorium,  extending  above  and  below  it. 

Structure.  —  1,  Elements.  This  region  owes  its  firmness  to  an 
osseous  base,  formed  by  the  mastoid  portion  of  the  temporal  bone, 
the  posterior  and  inferior  angle  of  the  parietal  bone,  and  by  a  small 
portion  of  the  occipital  bone,  which  are  united  by  the  mastoid  and 
squamous  sutures.  The  mastoid  foramen,  the  portion  of  the  lateral 
groove  which  there,  exists,  and  also  the  mastoid  cellules,  which  are 
situated  internally,  communicate  with  the  tympanum  and  are  lined 
with  its  membrane.  The  external  and  internal  periostea  are  remark- 
able ;  the  external  is  dense  and  adheres  firmly  by  the  numerous 
muscles  which  are  attached  to  it;  the  internal,  the  dura  mater, 
contains  the  lateral  sinus,  which  arises  at  the  base  of  the  fold.  The 
small  retrahens  auriculas  muscle,  of  which  more  than  one  sometimes 
exists,  and  the  auricular  ligament  belong  to  this  region  with  some 
fibres  of  the  occipitalis,  of  the  stern omastoideus,  of  the  splenius,  and  of 
the  trachelo-mastoideus  muscles,  which  there  terminate.  The  skin 
and  the  parietal  fold  of  the  arachnoid  membrane  present  nothing 
remarkable ;  hut  little  of  -cellular  tissue  exists  there  ;  it  is  very  dense, 
particularly  on  the  inside  of  the  bone. 

The  mastoid  arteries  all  come  from  the  posterior  auricular  and  the 
occipital  artery,  the  trunks  of  which  are  placed  on  the  boundaries  of 
the  region ;  the  last  sends  a  meningeal  branch  through  the  mastoid 
foramen.  All  the  veins  follow  the  course  of  the  arteries,  except  the 
great  emissary  mastoid  vein,  which  goes  to  the  lateral  sinus ;  the 
lymphatic  ganglions  occupy  the  mastoido-auricular  fissure ;  they 
receive  the  lymphatic  vessels  of  the  region,  and  also  several  from  the 


MASTOID    REGION.  53 

hairy  scalp,  as  we  have  already  seen ;  other  vessels  of  the  same  .order 
follow  the  course  of  the  occipital  artery. 

The  nerves  come  from  the  superficial  cervical  plexus,  and  are  given 
off  particularly  by  its  mastoid  and  auricular  filaments  ;  the  facial  also 
gives  off  some  which  anastomose  with  them.  The  nerves,  like  the 
vessels,  are  some  of  them  anterior,  they  are  the  auricular  filaments  of 
the  cervical  and  facial  plexuses  ;  the  others  are  posterior;  they  come 
from  the  mastoid  twig  of  the  cervical  plexus. 

2.  Relatio'ns.  The  skin  forms  the  first  layer ;  it  is  intimately  united 
to  the  deep  parts,  by  a  sub-cutaneous  cellular  tissue,  which  is  but 
slightly  adipose ;  more  deeply,  we  find  the  retrahentes  auriculae  and 
the  occipitalis  muscles,  the  attachments  of  the  sterno-mastoideus,  those 
of  the  splenius  below  it,  and'  finally,  those  of  the  trachelo-mastoideusr 
muscle  under  these  latter. 

On  the  inside  of  the  retrahens  auriculae  muscle,  appear  the  anterior 
vessels  and  nerves  in  the  mastoido-auricular  groove  ;  at  the  posterior 
part  of  the  region,  the  vessels  and  nerves  are  sub-cutaneous.  The 
external  periosteum  and  the  bones  come  next,  and  if  we  divide  them, 
we  penetrate :  first,  down  into  the  mastoid  cells,  and  after  passing 
through  them  and  their  internal  wall,  we  come  to  the  dura  mater  and 
the  parietal  fold  of  the  arachnoid  membrane;  second,  in  the  centre  of 
i  he  region,  we  fall  on  the  tentorium  of  the  cerebellum,  and  the  lateral 
sinus. 

Development.  The  mastoid  region  in  the  adult  is  very  firm,  but 
this  is  not  true  in  the  fetus  ;  the  bones  which  form  it  are  separated  by 
a  membranous  space,  which  continues  some  months  after  birth  ;  it  is 
the  posterior  and  lateral  fontanelle.  The  absence  of  the  mastoid 
process  in  early  life,  renders  this  region  much  less  extensive,  propor- 
tionally, than  in  the  adult ;  at  first,  the  mastoid  cells  do  not  exist ;  in 
aged  people,  on  the  contrary,  they  fill  the  whole  skeleton  of  this- 
region,  and  are  not  confined  even  to  the  temporal  bone. 

Varieties.  Bernard,  a  distinguished  physician  of  Toulouse,  has 
shown  us  a  child  which  presented  on  each  side  in  this  region  an 
accidental  auditory  passage,  communicating  with  the  regular  channel ; 
we  have  seen  no  instance  of  this  mentioned  in  any  author. 

Pathological  deductions  and  operations.  Hernia  of  the  encepha- 
lon,  whether  of  the  cerebrum  or  cerebellum,  may  occur  through  the 
fontanelle.  in  this  region  :  but  they  are  not  most  frequent  in  this. place. 
Wounds,  whether  anteriorly  or  posteriorly,  may  be  attended  with 
hemorrhage,  as  the  vascular  trunks  of  this  region  are  situated  anteri- 
orly and  posteriorly;  the  bones  are  sometimes  fractured,  with  depres- 
sion toward  the  tympanum  only,  which  at  first  view,  might  be  easily 
considered  a  more  serious  injury.  Caries,  necrosis,  or  exostoses  of 


54  TOPOGRAPHICAL    ANATOMY. 

the  mastoid  process,  are  not  unfrequent  in  syphilitic  affections. 
Abscesses  in  this  region,  which  are  generally  caused  by  an  alteration 
in  its  osseous  portion,  often  show  themselves  at  a  late  period,  by  point- 
ing, as  we  have  already  said,  in  the  auditory  passage.  The  tumors 
which  exist  in  the  mastoido-auricular  groove,  may  be  produced  symp- 
tomatically  in  diseases  of  the  occipito-frontal  region ;  they  are  engorge- 
ments of  the  lymphatic  ganglions.  The  skin  of  this  groove  is  very 
subject  to  scrofulous  ulcerations,  in  young  children  ;  the  mastoid 
emissary  vein  explains  the  correctness  of  the  principle  generally  given, 
to  apply  leeches  on  this  region  in  cerebral  affections.  It  was  proposed 
by  Jasser,  a  Prussian  surgeon,  to  open  in  this  place  an  artificial 
passage,  on  the  mastoid  cellules,  for  different  purposes,  particularly  to 
admit  the  air  into  the  cavity  of  the  tympanum,  when  the  Eustachian 
tube  was  obliterated.  This  operation  is  practicable  only  in  the  adult, 
since  the  mastoid  cells  do  not  exist  until  then ;  it  gives  the  individual 
an  accessory  auditory  passage  in  the  mastoid  region.  This  operation 
is  certainly  rational :  the  facility  of  performing  it,  the  few  parts  which 
are  interested,  if  we  avoid  the  mastoido-auricular  fissure  where  the 
nerves  and  vessels  are  situated,  the  freedom  with  which  the  air  must 
penetrate  through  this  passage  which  may  be  regarded  as  an  artificial 
Eustachian  tube,  and  the  preservation  of  the  membrane  of  the  tym- 
panum are  certainly  in  its  favor  ;  this  latter  circumstance  should 
cause  it  to  be  preferred  to  the  perforation  of  the  membrane  of  the 
tympanum,  proposed  by  Cooper.  The  fatal  accident  which  happened 
to  Just,  physician  to  the  king  of  Denmark,  who  died  of  erysipelas, 
after  this  operation  had  been  performed  upon  him  by  Professor  Koel- 
pin,  of  Copenhagen,  should  not  cause  it  to  be  abandoned ;  in  fact,  any 
operation,  however  trivial,  may  cause  serious  symptoms ;  even  vene- 
section, and  the  most  simple  incision  of  the  soft  parts,  have  sometimes 
been  attended  with  them,  yet  these  operations  are  still  performed. 


ORDER      THIRD. 

INFERIOR    WALL    OF    THE    CRANIUM. 


This  wall  of  the  cranium  belongs  to  it  only  by  one  of  its  surfaces, 
the  superior ;  the  inferior,  on  the  contrary,  blends  with  the  face  and 
the  neck,  where  we  shall  treat  of  it ;  our  remarks  here,  then,  will  be 
very  brief;  it  forms  a  region,  that  of  the  base  of  the  cranium. 

REGION   OF   THE   BASE   OF   THE   CRANIUM. 

This  region  represents  the  base  of  the  arch  of  the  cranium ;  it  is 
flattened  and  semi-circular,  and  arranged  so  that  its  anterior  part  rises 
above  the  central,  and  this  above  the  posterior. 


REGION   OF   THE   BASE   OF   THE   CRANIUM.  55 

Structure. —  1.  Elements.  Its  skeleton  is  thick,  and  formed  by 
bones  which  have  many  of  the  characters  of  the  short  bones  ;  it 
presents  numerous  openings,  through  which  pass  a  great  many  vessels 
and  nerves ;  it  forms,  a  little  posteriorly,  the  occipital  foramen ;  the 
internal  periosteum  adheres  to  it  in  a  direct  ratio  with  the  number  of 
its  different  openings,  and  it  contains  many  sinuses,  the  circular  and 
the  transverse  sinuses  of  the  sella  turcica,  the  transverse  sinus  of  the 
basilar  surface,  the  circular  sinus  of  the  occipital  foramen  of  Ridley, 
the  occipital,  the  cavernous,  and  the  superior  and  inferior  petrous 
sinuses.  The  parietal  fold  of  the  arachnoid  membrane  exists  in  every 
part ;  it  enters  into  each  opening,  and  forms  there  a  small  cul-de-sac, 
arid  soon  reflects  on  the  nerves  and  vessels  to  re-enter  into  the  skull. 
The  anterior,  middle,  and  posterior  meningeal  arteries,  come  from  the 
sources  already  mentioned,  with  their  attendant  veins  ;  but  we  find  in 
every  part,  numerous  emissary  veins,  which  come  from  the  nasal 
fossae,  through  the  foramen  lacerum,  and  many  other  foramina,  which 
are  very  apparent  on  the  sella  turcica;  the  ophthalmic  vein, also, by  its 
opening  with  the  cavernous  sinus,  presents  the  arrangement  of  the 
emissary  veins  ;  but  little  is  known  of  the  lymphatic  vessels.  There 
are  no  nerves  in  this  region,  except  those  which  pass  through  this 
wall. 

2.  Relations.  These  are  extremely  simple,  and  are,  considered 
from  without  inward,  the  bones,- the  dura  mater,  and  the  arachnoid 
membrane.  All  the  sinuses  occur  in  the  middle  and  posterior  planes 
of  the  region  of  the  base  of  the  cranium ;  the  first  are  situated  above 
or  on  the  sides  of  the  sella  turcica ;  the  second  on  the  edges  of  the 
petrous  process,  on  the  basilar  groove,  on  the  sides  of  the  internal 
occipital  crest,  and  around  the  occipital  foramen.  The  cavernous 
sinus  is  situated  on  the  side  of  the  sella  turcica,  and  contains  within  it 
the  internal  carotid  artery,  on  the  outside  of  which  the  nerve  of  the 
sixth  pair,  and  two  ascending  filaments  of  the  superior  cervical  gan- 
glion of  the  great  lymphatic  nerve  are  situated ;  in  its  external  wall, 
on  the  contrary,  are  placed  from  above  downward,  the  nerve  of  the 
third  pair,  that  of  the  fourth  pair,  and  the  ophthalmic  branch  of  the 
fifth  pair ;  these  last  two  are  situated  forward,  on  the  same  plane, 
above  the  first. 

Development.  The  bones  of  this  region  are  formed  and  united 
rapidly,  and  never  present  any  fontanelles. 

Pathological  deductions  and  operations.  A  part  or  the  whole  of 
this  region  may  be  deficient ;  we  possess  the  head  of  a  fetus,  in 
which  the  cribriform  plate  of  the  ethmoid  bone  is  absent.  When  this 
wall  of  the  cranium  is  entirely  deficient  the  whole  cranium  is  wanting; 
in  this  respect  this  wall  differs  from  the  others  ;  its  priority  of  develop- 


56  TOPOGRAPHICAL   ANATOMY. 

ment,  and  its  uses,  as  it  serves  to  sustain  the  whole  cavity,  sufficiently 
explain  this  curious  result.  These  functions  account  for  fractures  of 
this  region,  which  are  always  caused  by  counter-blows ;  when  effu- 
sions exist  in  the  space  between  the  dura  mater  and  the  bones,  they 
are  circumscribed  and  very  flat,  on  account  of  the  intimate  adhesion 
of  these  parts.  The  severity  of  the  fractures  depends  on  causes  dis- 
connected with  this  wall ;  we  shall  speak  of  them  soon.  Pus  some- 
times forms  in  the  sinuses  ;  we  have  seen  the  two  cavernous  sinuses 
filled  with  it.  Fungous  tumors  may  arise  from  the  dura  mater,  and 
proceed  externally  toward  the  neck  or  the  face.  At  the  hospice  of 
Bicetre,  we  dissected  one  which  had  destroyed  the  cribriform  plate  of 
the  ethmoid  bone,  and  had  proceeded  into  the  olfactory  cavities.  We 
will  speak  hereafter  of  the  use  which  may  be  made  of  the  emissary 
veins,  which  come  from  the  nasal  fossee  and  from  the  orbit. 


PARAGRAPH   SECOND. 

CAVITY   OP    THE    SKULL. 


The  different  regions  which  have  been  described,  enclose  a  cavity 
which  may  be  termed  the  cranial,  encephalic,  cerebral  cavity,  &c.  Its 
oval  form,  its  variable  dimensions,  do  not  belong  to  our  work ;  we 
refer,  on  this  subject,  to  the  excellent  treatises  on  descriptive  anatomy 
by  Meckel,  Boyer,  Bichat,  &c. 

.  This  cavity  is  regularly  separated  into  two  secondary  cavities,  by  a 
horizontal  fold  of  the  internal  periosteum  of  the  cranium,  the.  tento- 
rium.  One  is  termed  the  cerebral,  the  other  the  cerebellar.  The  first 
is  upper  and  anterior,  is  larger,  and  is  imperfectly  partitioned  by  the 
falx  of  the  dura  mater :  the  occipito-frontal,  the  temporal,  the  auricular, 
and  a  part  of  the  mastoid  region  belong  to  it.  with  the  two  anterior 
planes  of  that  of  the  base  of  the  skull.  The  second,  situated  lower 
and  posteriorly,  is  smaller,  and  is  regularly  divided  by  the  falx  of  the 
cerebellum ;  the  posterior  plane  of  the  region  of  the  base  of  the  skull, 
belongs  to  it  exclusively,  with  the  lower  part  of  the  mastoid  region. 
The  communication  between  these  two  sections  of  the  cavity  of  the 
cranium  is  oval,  and  rests  on  the  basilar  groove.  It  is  formed  in  great 
part  by  the  tentorium  of  the  cerebellum.* 

The  cerebrum  occupies,  the  whole  anterior  cavity  with  which  it  is 
connected  above,  by  some  veins,  below  by  some  nerves  and  large  arte- 

*  It  is  only  in  animals,  where  the  posterior  part  of  the  cerebrum  is  but  slightly  developed 
that  we  can  say,  that  the  tubercular  quadrigemina  are  protected  in  this  point  by  the  portion  of 
the  occipito-frontal  region,  the  skeleton  of  which  is  formed  by  the  upper  part  of  the  occipital 
region,  the  superior  occipital  bones. 


OF  THE  CAVITY  OF  THE  SKULL.  57 

ries.  The  cerebellum  is  situated  in  the  posterior  cavity,  and  is 
united  with  it  only  by  some  veins.  Over  the  communication,  we  find 
the.  mesocephalon,  which  is  continuous  with  the  spinal  marrow: 
this  latter  is  connected  anteriorly  with  the  edge  of  the  opening  by 
some  nerves  and  arteries  ;.  it  is  attached  there  posteriorly  by  the  veins 
of  Galen.  These  nervous  centres  are  lined  by  the  visceral  fold  of 
the  arachnoid  membrane,  which  is  continuous  with  the  parietal  fold, 
on  the.vessels  and  nerves  which  pass  from  the  cerebrum  to  the  parietes 
of  the  cranium,  or  reciprocally,  and  which  touches  only  the  top  of  the 
circumvolutions,  closing  the  grooves  between  them :  the  pia  mater 
lies  under  it ;  it  follows  all  the  sinuosities  of  the  surface  of  the  enceph- 
alon,  differing  in  this  respect  from  the  arachnoid  membrane.  A 
more  .ample  .description  of  the  reciprocal  arrangement  of  these  two 
membranes,  and  of  the  different  portions  of  the  encephalon  is  curious, 
and  belongs  to  descriptive  anatomy :  for .  it,  we  refer  to  the  works 
already  mentioned,  and  particularly  to  Meckel :  we  will  only  remark, 
that  the  arteries,  of  the  brain  send  some  branches  to  the  outside  of  the 
skull,  into  the  cavities  of  the  internal  ear,  of  the  eye,  and  even  of 
the  forehead,  between  the  nervous  centres  .  and  these  regions :  we 
should  remember  that  the  prominences  which  give  rise  to  the  nerves, 
and  which  consequently  maintain  life,  rest  on  the  region  of  the  base 
of  the  skull,  which  in  most  points  is  amply  protected  from  external 
injuries. 

Development.  According  to  all  appearances,  the  cavity  is  at  first 
open,  but  it  soon  closes. 

Varieties*  Its  varieties  of  capacity  are  very  numerous,  and  depend 
on  those  in  the  size  of  the  encephalon  ;  Ribes  has  proved  that  in  old 
persons  this  cavity  diminishes  by  the  collapse  of  its  parietes. 

Pathological  deductions  arid  operations.  Hernias  of  the  internal 
organs  of  the  skull  may  exist ;  these  have  been  mentioned  already. 
The  cavity  may  be  contracted  by  the  depression  of  a  part  of  its 
osseous  envelope,  in  fractures  :  in-  these  -cases  trepanning  is  indicated. 
Effusions  of  different  natures  occur  on  the  loose  surface  of  the  serous 
membrane,  and  are  necessarily  diffused,  as  when  they  are  situated  in 
the  pia  mater,  on  the  surface  of  the  cerebrum  :  but  this  is  not  true  of 
those  within  the  brain:  when  the  fluid  is  contained  at.  first  in  a 
ventricle,  it  soon  extends  into  the  others,  on.  account  of  the  easy  com- 
munication which  naturally  exists  .between  them,  especially  between 
the  middle  and  the  two  lateral  ventricles.  If,  however,  we  connect  our 
opinions  on  effusions  within  the  cavity  of  the  skull  with  those  sug- 
gested when  speaking,  of  its  parietes,  and  determine  generally  in 
what  cases  of  effusion  trepanning  is -required,  we  shall  see  that  this 
operation  can  be  useful  only  when  the  effusion  on  the  inside  of  the 


58  TOPOGRAPHICAL     ANATOMY. 

bones  being  circumscribed ;  first,  it  is  indicated  only  in  those  situated 
between  the  bones  and  the  dura  mater,  between  this  and  the  parietal 
arachnoid  membrane,  or  in  the  substance  of  the  brain ;  second,  that 
it  should  be  avoided,  as  improper,  in  those  of  the  cavities  of  the  arach- 
noid membrane  or  of  the  ventricles,  or  when  they  are  situated  in  the 
loose  tissue  of  the  pia  mater.  It  is  difficult  to  estimate  the  different 
situations  of  these  effusions,  it  is  only  important  to  determine  whether 
the  effusion  be  circumscribed  or  not,  in  other  words,  whether  the  ope- 
ration of  trepanning  be  indicated  or  not.  An  effusion  is  circumscribed, 
when  it  causes  a  local  compression  which  is  attended  with  a  well 
defined  paralysis  on  one  side  of  the  body:  it  is  diffused,  if  it  be  followed 
by  a  semi-paralysis  which  affects  both  sides  of  the  body.  We  cannot 
be  certain  whether  an  effusion  is  situated  anteriorly  or  posteriorly ; 
in  regard  to  the  side,  it  is  generally  opposite  to  that  paralyzed;*  these 
latter  circumstances  are  so  vague,  that  they  prevent  us  from  trepan- 
ning in  cases  of  effusion  not  traumatic.  The  greater  size  of  the 
cerebrum,  and  particularly  its  direct  relation  with  the  occipito- 
frontal  region,  which,  is  the  most  exposed  to  external  injuries,  explain 
the  frequency  of  its  traumatic  injuries,  while  those  of  the  cerebellum 
are  extremely  rare :  on  the  other  hand,  we  can  easily  conceive  of  the 
severity  of  injuries  of  the  base  of  the  skull,  especially  of  effusions 
in  that  part  caused  by  fractures,  when  we  remember  that  the  nervous 
enlargements  which  directly  sustain  life  by  giving  off  the  respiratory 
nerves,  rest  on  this  wall.  It  is  even  curious  to  compare  these  lesions, 
which  are  frequently  very  small  and  fatal,  with  those  of  the  arch  of 
the  cranium,  and  of  the  cerebrum,  which  are  more  extensive  and  often 
simple :  in  fact,  the  upper  part  of  the  encephalon  belongs  but  very 
slightly  by  its  functions  to  the  organic  life,  it  is  devoted  entirely  to 
that  of  relation.  The  arterial  connection  of  the  brain  with  the  ear, 
the  eye,  and  the  forehead,  explains  the  burning  of  the  ear,  the  redness 
of  the  eye,  the  pains  in  the  forehead;  symptoms  which  are  so 
common  in  even  the  slightest  cerebral  affections. 

*  This,  however,  is  not  always  the  case :  we  have  the  records  of  two  cases  of  apoplectic 
individuals,  in  whom  it  was  proved  by  post  mortem  examination,  that  the  effusion  might  be 
situated  on  the  side  of  the  paralysis ;  in  these  two  cases,  the  posterior  extremity  of  the 
hemispheres  was  affected.  If  we  add  that  Gall  has  demonstrated  that  the  fibres  of  the 
olivary  eminences  communicate  with  this  part  of  the  cerebrum,  that  they  do  not  intercross  in 
the  superior  bulb  of  the  medulla  like  those  of  the  pyramids,  and  that  the  latter  expand  in  the 
skull  and  form  nearly  all  the  hemispheres,  we  shall  account  for  the  paralysis  on  the  side 
of  the  effusion,  in  rare  cases  where  the  posterior  part  of  the  hemispheres  is  alone  affected,  and 
of  the  paralysis  on  the  opposite  side,  which  commonly  supervenes,  because  the  effusions  most 
rrcquently  take  place  in  the  course  of  the  expanded  fibres  of  the  pyramid. 


OF   THE    PACE. 


ARTICLE    II. 


OF       THE       FACE. 

The  face  is  the  portion  of  the  head  destined  particularly  for  the 
organs  of  the  senses;  it  is  blended  above  with  the  cranium,  below  and 
backward  with  the  neck ;  it  is  unattached  forward  and  on  the  sides. 
Its  variations  in  the  races  of  the  human  species,  and  in  animals,  are 
very  numerous  ;  we  must  mention  them  merely  in  a  general  manner, 
at  the  same  time  that  we  point  out  the  laws  to  which  they  are  sub- 
mitted;  we  shall  first  attend,  however,  to  the  face  in  the  adult. 

It  is  very  difficult  to  define  the  shape  of  the  face ;  the  form  of  a 
quadrangular  pyramid  with  its  summit  truncated  posteriorly,  which  is 
mentioned  by  authors,  gives  only  an  imperfect  idea  of  it.  The  face 
occupies  the  anterior  part  of  the  head,  and  its  direction  is  a  little 
oblique  to  the  horizon,  with  which  it  forms  an  angle  from  seventy  to 
ninety  degrees ;  this  facial  angle,  the  importance  of  which  has  been 
demonstrated  by  Camper,  must  be  included  between  the  frontal 
protuberance  and  the  anterior  part  of  the  jaws. 

The  size  of  the  face  in  the  adult,  is  only  a  fourth  of  that  of  the 
head  ;  it  is  one  third  of  that  of  the  skull.  The  best  mode  of  making 
this  calculation  is  to  consider  a  head  in  profile,  or  rather,  as  M.  Cuvier 
advises,  to  make  a  perpendicular  section  of  it.  This  examination  also 
demonstrates,  that  as  the  anterior  part  of  the  face  is  almost  the  only 
unattached  part,  the  variations  in  development  are  manifested  only  in 
it;  hence  it  follows,  that  the  facial  line  of  Camper,  if  it  belonged  only 
to  the  anterior  plane  of  this  great  region,  would  indicate  with  exact- 
ness its  absolute  size  by  its  angle  with  the  horizon ;  but  its  extremities 
are  common  to  the  skull  and  the  face ;  its  direction,  consequently, 
being  influenced  by  these  two  parts,  can  afford  conclusions  only  in 
regard  to  their  proportional  development. 

Structure.  The  face,  being  situated  at  the  upper  extremity  of  the 
air  passages  and  digestive  tube,  forms  cavities  which  protect  the  three 
principal  organs  of  the  senses,  and  shares  some  of  its  elements  with 
the  cranium  and  the  neck.  Its  skeleton  is  represented  by  the  jaws ; 
the  muscles  are  attached  to  the  bones  mostly  by  one  extremity  only. 
Numerous  arteries  are  given  off  to  it,  especially  by  the  internal  and 
external  maxillary  arteries ;  these  arteries  are  attended  with  veins. 
These  different  vessels  frequently  anastomose  with  each  other,  and 
with  those  of  the  cranium.  Two  nerves  are  distributed  principally 
to  the  face ;  the  facial  nerve  for  the  respiratory  motions  and  for  the 


flO  TOPOGRAPHICAL  ANATOMY. 

expression,  and  the  tri facial  nerve  for  the  general  sensibility,  and  for 
the  motions  required  by  digestion;,  The  cellular  tissue  is  dense  on 
the  median  line ;  it  is  more  abundant  and  -looser  on=the  sides.  The 
skin  is  remarkable  for.  its' .'thickness,  ils  vascularity,  its  numerous  folli- 
cles, and  its  hairs;  it  is  continuous  with  the  mucous  system  at  the 
openings  of  the  eyelids,  of  the  nose,  and  .of  the  mouth. 

Development,  The  face  is  formed  very  early  in  the  fetus  ;  at  first 
view,  it  would  seem  to  be  an  exception  to  the  general  law  of  develop- 
ment of  the  trunk  by  two  lateral  halves;*  but  this  is  not  the  case. 
Its  existence  is  connected  with  that  of  the  organs  of  the  senses,  and 
with  the  nerves  which  belong  to  them. 

During  infancy,  the  absolute  size  of  the  face  is  very  small ;  this  is 
true  'also,  of  its  size  compared  with  that  of  the  cranium,  which  may 
be  inferred  from  the  great  development  of  the  latter,  and  from  our 
remarks  upon  the  inverse  ratio  between  these  two  parts  of  the  head. 
The/«cia£  line  is  then  vertical,  the  angle  it  forms  with  the  horizon  is 
a  right  angle,  and  gives  a  peculiar  character  to  the  whole  head; 

At  a  later  period,  when  the  deciduous  teeth  are  formed,  the  face 
increases  very  much,  the  skull  remaining  almost  stationary ;  the  face 
begins  to  project,  the  facial  line  is  inclined,  and  its  angle  becomes 
more  and  more  acute.  This  arrangement  exists  in  the  greatest  degree 
at  the  age  of  twenty  five  or  thirty,  when  the  wisdom  teeth  are  formed, 
and  give  the  face  a  greater  development,  throwing  the  jaws  forward, 
In  the  old  man,  the  face  is.  inclined,  still  niore,  and  the  facial  angle 
becomes  also  more  acute;  this,  however,  does  not  depend  upon  its  real 
enlargement,  but  rather  on  the  collapse  of  the  cranium,  and- the 
torsion  of  the  face  forward,  which  torsion  is  caused  by  the  maxillary 
bones,  which  at  the  same  time  become  lower.  The  eifect  of  this . 
shortening  of  the  face,  which  is  communicated  to  it  by  its  skeleton,  is 
a  relaxation  of  the  soft  parts,  which  loose  their  elasticity,  fold,  and 
form  more  or  less  distinct  wrinkles. 

Varieties.  In  the  female,  the  face  is  narrower  across  than  in  the 
mate ;  it  is  also  smaller.  Generally  speaking,  the  facial  angle  in  the 
Caucasian  race,  is  eighty  degrees,  while  it  is  not  more  than  seventy- 
five  or  seventy  in  the  Mongolian  or  in  the  .African  race.t  A  much 

*  The  separate  facts  related  by  authors  on  the  development  of  the. mouth  and  the  .nostrils, 
would  seem  to  show  in  fact  that  the  face  is  formed  by  three  pieces,  a  median  and  two  lateral 
parts. 

t  Authors  are  wrong  in  stating  with  Ovid  that  one  of  the  characters  of  human  nature 
consists  in  the  direction  of  the  face  and  eyes  towards  the  heavens. 

"  OB  homini  sublime  dcdit,  coelumque  tugri 
Jussit,  eterectos  ad-sidera  tollere  vultus.' 

In  fact  this  arrangement  becomes  more  and. more  marked  as  we  descend  in  the  scale  of  ani- 
mals, and  the  fish  termed  vrdnoscopia  presents  it  in  a  greater  degree  than  man. 


OP  THE   FAC:E.  61 

greater  and  very  remarkable  gradation  is  observed  in  animals;  These 
measurements  are  highly  important,  as  they  indicate  the  proportional 
development  of  the  face,  and  of  the  cranium,  and  lead  to  an  estimate  of 
the  size  of  the  brain,  and  to  a  certain  extent,  of  the  degree  of  intelligence. 
The  ancients  understood  this  truth  so  well,  that  in  order  to  give  more 
majesty  to  the  figures  of  their  gods  and  heroes,  they  elevated  the  facial 
line  so  that  it  was  almost  vertical ;  the  owl,  with  them,  is  an  emblem 
of  wisdom,  but  storks,  on  the  contrary,  are  emblems  .of  weakness  and 
foolishness.  In  every  case,  in  animals  and  also  in  man,  although  this 
objection  has  less  weight  with  him,  we  must  regard  the  development 
of. the  forehead  by  the  formation  of  the  frontal  sinuses;  without  this 
precaution,  we  should  be  constantly  led  into  error,  admitting  in  some 
individuals  a  capacity  of  the  cranium,  and  consequently  a  degree  of 
intelligence,  which  they  do  not  .possess.*  We  can  then  imagine  that 
in  the  child,  in  whom  these  sinuses  do  not  exist,  the  facial  line  may 
furnish  more  exact  results  than  in  the  old  man.  Such  are  the  great 
varieties  of  the  face  in  the  principal  human  races,  varieties  which  may 
be  measured  also  by  comparison  with  the  cranium,  although  this  can 
be  obtained  directly  by  calculating  its  area,  and  comparing  the  results 
obtained  in  different  individuals ;  but  this  estimate  cannot  be  made, 
except,  upon  heads  dried  and  prepared  expressly.t 

Uses.  Besides  the  uses  of. protecting  the  organs  of  the  senses,  the 
face  performs  various  motions,  which  modify  it  very  much,  and  take 
place  in  its  lower  part  ;J  while- the  upper,  which  is  motionless,  serves 
as  a  point,  of  support,  and  communicates  to  the  cranium,  with  which 
it  is  united,  the  motions  transmitted  to  it. 

Pathological  deductions  and  operations.  The  face  may  be  entirely 
deficient,  aprosopia ;.  Lecat,  Curtius,  and  Beclard  have  related 
instances  of  it.  This  -deviation  of  formation,  however,  in  which  the 
ears  are  inclined  downward,  and  are  very  near  each  other,  is  seldom 
so  extreme,  that  some  imperfect  rudiments  of  the  face  do  not  exist  on 
the  sides.  The  median  parts^  are  often  deficient,  the  lateral  being 

*  We  must  also  remember,  that  the  capacity  of  the  skull  does  not  always  give  the  degree 
of  intelligence,  because  some  of  the  parts  which  are  situated  in  this  cavity,  which  have  no 
connection  with  the  intellectual  functions,  may  by  their  development,  require  a -very  large 
brain-case. 

t  Other  modes  besides  the  facial  line  have  been  proposed,  to  arrive  at  the  variations  of  the 
face  in  the  different  races  of  men  and  animals,  but  all,  except  that  of  Cuyier  which  has 
been  stated,  give  only  the  proportional  development  of  the. skull  and  face. 

J  In  man,  the  upper  part  of  the  face  does  not  move  upon  the  lower,  as  it  does  in  venomous 
serpents:  but  this  abnprmal  motion  is  observed  in  him,  when  the  motions  of  the  lower  jaw 
are  prevented:  the  upper  part  of  the  face,  then,  simply  follows  the  skull,  which  is  thrown 
back  on  the  vertebral  column. 


62  TOPOGRAPHICAL    ANATOMY. 

blended  together ;  finally,  sometimes  we  observe  more  or  less  central 
fissures,  evidently  from  the  arrest  of  development. 

The  face  is  composed  of  three  very  distinct  groups ;  the  nostrils,  the 
mouth,  and  the  orbits ;  it  also  includes  the  zygomatic  fossa,  which 
is  a  small  region,  enclosed  between  the  cranium  and  the  face. 


PARAGRAPH     FIRST. 

NOSTRILS. 

The  nostrils  are  anfractuous  cavities,  which  are  designed  to  receive 
the  impressions  of  smell.  They  are  situated  at  the  upper  part  of  the 
air  passage,  of  which  they  may  be  considered  as  a  modification. 
Their  limits  are  very  exact ;  they  are  placed  between  the  base  of  the 
cranium  and  the  mouth,  having  on  the  outside  the  region  of  the 
cheeks,  the  orbits,  and  the  summit  of  the  zygomatic  fossa,  which  they 
bound  in  their  turn  ;  they  open  externally,  forward ;  and  into  the 
pharynx,  backward. 

The  nostrils  are  nearly  similar;  they  are  formed  of  a  portion  which 
projects  in  the  face,  the  nose,  and  of  another  deep  seated  portion,  the 
nasal  fossa;  hence  two  regions,  the  external  olfactory,  and  the  inter- 
nal olfactory,  which  are  very  analogous  in  respect  to  their  internal 
surface,  structure,  development,  uses,  &c. ;  it  is  convenient,  then,  first 
to  give  a  general  description  of  the  nostrils,  which  are  formed  by 
these  regions ;  we  shall  then  examine  them  separately  ;  in  this  way 
we  shall  avoid  numerous  repetitions. 

The  surface  of  the  nostrils  is  very  extensive,  which  is  owing  to  the 
more  or  less  curved  prominences*  of  bone,  on  which  their  internal 
membrane  is  expanded,  and  also  to  the  prolongations  or  sinuses  which 
they  send  into  the  supraciliary  region,  the  region  of  the  base  of  the 
skull,  and  the  rnalar  region  ;  prolongations  which  we  shall  not  men- 
tion here.  The  first  arrangement,  while  it  increases  the  extent  of  the 
surface  of  the  nostrils,  singularly  contracts  their  cavity  in  the  corres- 
ponding points ;  this  is  the  largest  downward  and  forward. 

Structure.  The  parietes  of  the  nostrils  are  formed  by  a  skeleton 
which  varies  in  solidity ;  on  the  inside  of  this,  we  find  in  every  part  a 
fibro-mucous  membrane,  called  the  pituitary,  which  is  continuous 
anteriorly  with  the  skin,  and  posteriorly  with  the  mucous  mem- 
brane of  the  throat  and  tympanum,  particularly  with  the  latter, 
through  the..Eustachian  tube.  This  general  layer  receives  arteries 
from  different  sources ;  some  come  anteriorly  from  the  facial  artery ; 

*  These  prominences  or  turbinated  bones  are  twisted  in  a  direct  ratio  with  the  development 
of  the  olfactory  faculty.  Of  all  animals,  the  dog  is  the  most  remarkable  in  this  respect. 


OP    THE   NOSTRILS.  63 

others  come  to  it  from  the  orbit,  the  ethmoid  arteries ;  the  last  from 
the  zygomatic  region,  the  spheno-palatine,  the  pterygo-palatine,  and 
some  twigs  of  the  posterior  palatine  artery.  The  veins  generally 
follow  the  course  of  the  arteries,  except  the  small  emissary  vein  of  the 
fronto-ethmoidal  foramen,  which  goes  to  the  origin  of  the  superior  Ion 
gitudinal  sinus,  and  also  some  others  which  pass  through  the  sphenoid 
bone,  to  open  into  the  cavernous,  transverse,  and  coronary  sinuses. 
Thus  the  cerebrum  and  its  membranes  are  connected  with  the  nostrils 
by  the  veins  and  arteries,  particularly  the  ethmoidal.  The  lymphatic 
vessels  are  not  known,  except  anteriorly.  The  nerves  which  are 
common  to  the  two  parts  of  the  region  of  which  we  are  speaking, 
come  only  from  two  sources,  the  olfactory,  and  the  fifth  pair ;  this  latter 
sends  to  it  divisions  of  its  filaments,  the  spheno-palatine,*  the  posterior 
palatine,  the  internal  frontal,  and  the  infra-orbitar  nerve. 

Development.  The  nostrils  are  developed  by  several  pieces  which 
unite  on  the  median  line ;  two  lateral  pieces,  formed  of  secondary 
points,  represent  the  orbito-nasal  septa ;  two  others  in  the  centre,t  the 
median  septum.  These  parts  are  at  first  very  distinct,  but  afterwards 
unite  ;  the  lateral  appears  sooner  than  the  last.  This  regular  deve- 
lopment is  subordinate  to  that  of  the  olfactory  nerve ;  if  this  be  defi- 
cient, the  nostrils,  also,  are  generally  absent;  sometimes  they  are 
formed  but  irregularly ;  we  possess  a  remarkable  instance  of  this  in  a 
fetus,  where  the  median  septum  and  also  the  cribriform  plate  of  the 
ethmoid  bone,  which  make  a  part  of  it,  are  entirely  deficient ;  the 
cerebrum  of  this  individual  has  only  one  median  lobe. 

Varieties.  In  the  infant  and  the  old  man,  the  cavities  of  the 
nostrils  are  narrow,  for  opposite  reasons;  the  slight  transverse 
development  of  the  whole  of  this  region  in  the  former,  a  considerable 
prominence  of  the  turbinated  bones  in  the  latter. 

Sometimes  the  septum  is  perforated,  although  this  may  result 
neither  from  an  operation  nor  from  disease  ;  sometimes  it  is^displaced 
toward  one  side. 

Pathological  deductions  and  operations.  By  a  slow  suspension  of 
development,  such  as  we  have  described,  we  find  the  nostrils  blended 
together,  their  septum  being  absent.  If,  on  the  contrary,  the  develop- 
ment is  arrested  sooner,  the  nostrils  are  entirely  deficient,  anarinia, 


*  The  ganglion  of  Meckel,  which  aends  off  this  nerve  and  the  posterior  palatine  nerves, 
may  be  considered  simply  as  an  enlargement  of  the  superior  maxillary  nerve  of  the  fifth  pair. 

t  The  formation  of  the  nasal  septum  by  two  points,  is  far  from  being  admitted  by  authors  : 
we  have  ascertained  it  to  be  the  case  in  several  fetuses,  particularly  in  the  vomer,  which 
bone,  in  the  adult,  is  also  formed  of  two  layers,  which  arise  singly  in  the  fetus.  Thus  the 
development  of  the  nostrils  is  not  an  exception  to  the  general  development  of  the  trunk,  as 
iVwould  seem  at  first  view. 


64  TOPOGRAPHICAL    ANATOMY. 

and  the  orbits  are  blended,  or  separated  only  by  a  thin  septum. 
When  speaking  of  the  arch  of  the  palate,  we  shall  mention  the  divi- 
sion of  the  lower  wall  of  the  nostrils.  The  communication  between 
the  vessels,  which  "we  have  stated  as  existing  between  the  brain  and 
the  face,  accounts  for  those  epistaxes  and  those  corizas  which  supervene 
in  affections  of  the  cerebrum,  and  sometimes  serve  as  crises.  The 
advice  .given  by  some  practitioners,  to  apply  leeches  on  the  pituitary 
membrane  in  the  same  cases,  is  also  founded  on  the  same  anatomical 
arrangement. 


1.     E  X  T  E  R  N  A  L      O  L  F  A  C  T  O  R  Y      REGION. 


"The  nose  is  that  portion  of  the  olfactory  apparatus  which  projects  in 
the  face.  Its  form  is  pyramidical ;  it  is  separated  above  from  the  fore- 
h6ad  and  the  eyebrows  by  a  very  marked  depression;  below,  it  is  united 
at  a  right  angle  with  the  upper  lip,  from  which,  also^  it  is  easily  distin- 
guished; on  the  outside,  it  is  separated  from  the  eyebrows  and  cheeks 
by  the  naso-palpebral  and  naso-malar  grooves,  The  nose  is  situated 
on  the  median  line  ;  it  is  symmetrical,  but  always  tends  a  little  to  the 
right  side  at  its  point;  this  depends,  according. to  Beclard,  on  the  habit 
of  wiping  the  nose  with  the  fight  hand. 

.  This  region  presents  two  surfaces ;  the  internal  is  hairy  and 
mucous,  and  forms  the  parietes  of  the  nasal  cavity:  the  external  is 
smooth  and  covered  with  skin,  and  presents,  especially  at  its  lower 
part,  numerous  and  very  evident  follicular  openings,  through  which 
the  slightest  pressure  causes  a  sebaceous  substance  to  .ooze  in  the 
forrn  of  little  worms.  This  surface  presents  ;  the  back  of  the  nose, 
which  varies  in  its  direction :.  the  alae  formed  by  planes  the  direction 
of  which  is  forward  and  outward;  the  root,  and  finally  the  base,  on 
which  we  observe  the  lobe  and  the  anterior  openings  of  the  nostrils, 
the  inside  of  which  descends -lower  than  the  outside :  this  arrange- 
ment, shows  in  a  profile  view  of  the  head,  the.  corresponding  opening 
of  the  nose. 

Structure,--].*  Elements.  The  nose  is  formed  of  a  skeleton,  which 
is  osseous  at  the  upper  part,  where  it  is  formed  by  the  nasal  bones  and 
the  ascending  processes  of  the  superior  maxillary  bones  :  cartilagino- 
membranous  at  the  lower  part,  where  we  find  the  cartilage  of  the  alae 
and  septum,  their  fibrous  membrane  and  the  membranous  cartilages 
of  the  openings.  We  would  also  remark,  that  the  septum  is.  osseous 
above  and  below,  and  is  formed  by  the  perpendicular  plate  of  the 
ethmoid  bone  in  the  first  point,  and  the  vomer  in  the  second.  The 


EXTERNAL   OLFACTORY    REGION.  65 

muscles  of  this  region  are  the  pyramidal  and  the  triangular  muscles, 
some  fibres  of  the  levator  labii  super ioris  alaeque  nasi,  and  of  the 
depressor  alee  nasi.  The  cellular  tissue  is  very  compact  at  the  lower 
part,  but  looser  above ;  but  little  fat  exists  there ;  more  of  it,  however,  is 
found  below.  The  existence  of  the  skin  and  of  the  pituitary  mem- 
brane has  already  been  mentioned.  The  arteries  of  the  nose  are 
numerous,  and  are  given  off  by  the  facial  artery,  or  by  its  superior 
labial  branch,  by  the  ophthalmic  and  infra-orbitar  arteries ;  a  small 
branch  passes  from  the  inside  to  the  outside,  through  a  foramen  in 
one  of  the  nasal  bones.  The  veins  of  the  nostrils  follow  the  course  of 
the  arteries  with  the  exception  mentioned  in  the  general  description. 
The  nerves  of  the  nose  come  principally  from  two  sources,  which  it  is 
curious  to  mention,  since  the  fine  experiments  of  Charles  Bell ;  some 
are  filaments  of  the  facial  nerve,  others  come  from  the  fifth  pair,  and 
particularly  from  the  infra-orbitar  and  nasal  branches  of  the  oph- 
thalmic nerve  of  Willis ;  this  latter  is  distributed  to  the  nose  by  its 
external  and  also  its  internal  twig,  so  remarkable  for  its  course,  and 
forms  the  nasal-lobar  filament :  the  upper  part  of  the  nose  receives 
some  twigs  of  the  olfactory  nerve. 

2.  Relations.  In  proceeding  from  without  inward,  the  following 
parts  present  themselves  in  a  very  regular  order ;  the  skin  is  attached 
firmly  below  by  a  cellulo-fatty  layer,  which  is  remarkably  dense  in 
this  point :  this  layer  is  distributed  generally,  and  in  it  are  found 
most  of  the  vessels  and  nerves  :  next  comes  another  layer,  formed  by 
the  pyramidal,  the  triangular,  and  the  common  levator  muscles ;  below 
the  triangularis  muscle  appear ;  the  naso-lobar  nerve,  and  the  osseo- 
cartilaginous  and  membranous  skeleton;  next  the  pituitary  membrane, 
and  then  we  come  into  the  olfactory  cavity. 

Varieties.  The  nose  presents  numerous  varieties,  which  generally 
depend  on  the  variable  position  of  its  back;  this  is  convex  in  the 
aquiline  nose,  concave  in  the  turned  up  nose,  and  flat  in  the  broad 
flat  nose.  Beclard  remarks,  that  in  left  handed  people  the  nose  is 
inclined  to  the  left. 

Pathological  deductions  and  operations.  The  nose  participates  in 
all  the  general  defects  of  the  nostrils  ;  sometimes  it  alone  is  deficient ; 
this,  however,  occurs  less  frequently  than  the  internal  olfactory 
region.  In  fact,  in  cyclopia.  where  the  nose  does  not  exist,  we 
generally  find  it  contracted  in  the  form  of  a  tube,  and  situated 
most  commonly  above,  rarely  below  the  single  orbit ;  sometimes  the 
openings  of  the  nose  are  obliterated.  Some  instances  of  a  double  nose 
are  cited.  Fractures  of  the  nose  are  sometimes  serious,  which  are 
explained  very  readily  by  the  concussion  extending  from  the  proper 
bones  of  the  nose  to  the  perpendicular  plate  of  the  ethmoid  bone,  and 


66  TOPOGRAPHICAL  ANATOMY. 

from  this  to  the  horizontal  plate ;  hence  results  a  fracture  of  the  base 
of  the  cranium,  which  is  extremely  dangerous.  On  account  of  the 
great  vascularity  of  the  nose,  it  is  laid  down  as  a  precept,  to  unite  its 
wounds,  even  when  a  part  has  been  removed ;  nevertheless,  in  this 
case,  there  is  little  hope  of  success,  although  it  is  not  impossible. 
The  same  reasons  have  suggested  the  idea  of  making  a  new  nose, 
when  the  nose  is  deficient.  This  operation  seems  to  have  been 
invented  in  those  countries  where  criminals  are  punished  by  cutting 
off  the  nose  :  it  has  been  used  from  time  immemorial  by  the  Indians, 
and  their  method  is  certainly  much  more  rational  than  that  of  Talia- 
cozzi,  who  has  given  a  good  description  of  it ;  but  it  was  known  before 
him.  The  Indians  used  the  firm  skin  of  the  frontal  region,  but 
Taliacozzi  advises  to  form  a  new  nose  from  the  skin  of  the  fore  arm. 
In  both  cases  the  mutilated  edges  of  nose  should  be  pared  off,  and  we 
should  fit  upon  them  the  base  of  the  triangular  fold  which  has  been 
cut,  and  which  is  still  attached  by  its  point  to  the  place  from  whence  it 
was  taken.  The  nose  is  frequently  the  seat  of  tumors  of  various 
sizes  ;  these  are  generally  cutaneous  follicles  morbidly  developed ; 
the  follicular  nature  of  the  skin  easily  accounts  for  it.  The  distribu- 
tion of  the  naso-lobar  nerve  to  the  alae  of  the  nose,  and  also  its  origin 
from  the  nasal  nerve  of  the  external  branch  of  which  belongs  to  the 
eyelids,  has  caused  the  advice  sometimes  neglected,  of  applying 
blisters  on  the  alsB  of  the  nose  in  ophthalmia. 

INTERNAL  OLFACTORY  REGION  OR  NASAL  F  O  S  -S  JE . 

The  internal  olfactory  region  is  composed  of  the  anfractuous  part  of 
the  apparatus ;  which,  however,  must  not  include  the  sinuses  which 
are  connected  with  other  regions. 

It  is  situated  deeply  in  the  face,  and  is  continuous  with  the  nose. 
The  turbinated  bones  belong  to  it  particularly,  and  increase  the  sur- 
face of  the  olfactory  membrane  very  much,  contracting  the  transverse 
extent  of  this  cavity ;  above,  it  does  not  measure  more  than  three  or 
four  lines. 

The  internal  olfactory  cavity  is  bounded  by  parietes  which  present 
two  faces  ;  the  external  belongs  to  the  cranium  above,  to  the  arch  of 
the  palate  below,  and  on  the  outside  to  the  zygomatic  region  of  the 
orbit  and  cheeks :  the  internal  is  loose  and  mucous ;  it  is  plane  infe- 
riorly  and  internally ;  superiorly,  it  is  at  first  horizontal,  it  afterwards 
inclines  backward,  and  in  this  point  presents  the  opening  of  the 
sphenoidal  sinus,  which  is  extended  into  the  base  of  the  cranium ;  on 
the  outside,  it  is  irregular,  and  presents  three  prominences,  which  are 
convex  inward  and  concave  outward ;  these  are  the  turbinated  bones, 


INTERNAL  OLFACTORY  REGION.  67 

which  circumscribe  the  three  meatuses;  the  surfaces  of  both  diminish 
from  below  upward,  and  at  the  expense  of  their  anterior  part,  the  pos- 
terior continuing  unchanged :  the  inferior  turbinated  bone  descends  to 
within  two  lines  of  the  floor  of  the  cavity.  The  inferior  meatus, 
which  is  the  largest  and  extends  the  farthest  forward,  presents  the  only 
opening  of  the  nasal  canal,  an  opening  which  is  provided  with  a 
valvular  mucous  fold  which  floats  inferiorly,  and  is  concealed  by  a 
prominence,  the  importance  of  which  was  first  demonstrated  by 
Beclard ;  this  prominence  is  formed  particularly  by  the  root  of  the 
ascending  process  of  the  superior  maxillary  bone.  The  middle 
meatus  presents  the  contracted  opening  of  the  maxillary  sinus  and 
that  which  is  common  to  the  frontal  sinuses,  and  to  the  anterior  eth- 
moidal  cellules  ;  this  latter  is  continuous  by  a  very  apparent  groove, 
an  arrangement  generally  but  little  known.  The  internal  and 
osseous  portion  of  the  lachrymal  sac  is  situated  before  this  meatus, 
and  not  on  a  level  with  it.  The  superior  meatus  presents  anteriorly, 
the  opening  or  openings  of  the  posterior  ethmoidal  cellules,  while  the 
sphenopalatine  foramen,  and  the  zygomatic  region  look  to  its  posterior 
part.  These  different  parietes  are  continuous  forward,  directly  with 
those  of  the  nose,  and  backward,  with  that  of  the  pharynx  or  a  quad- 
rilateral opening,  the  outside  of  which,  at  its  centre,  looks  to  the 
extremity  of  the  eustachian  tube,  while  the  lower  is  extended 
by  the  velum  palati. 

Structure. — 1.  Elements.  The  skeleton  of  the  olfactory  region  is 
entirely  bony ;  the  cribriform  plate  of  the  ethmoid  and  the  sphenoid 
bone ;  the  horizontal  part  of  the  maxillary  and  palatine  bones 
below ;  the  vomer  and  the  perpendicular  plate  of  the  ethmoid  bone  on 
the  inside ;  the  ethmoid  bone  also  by  its  lateral  masses  which  are 
grooved  with  cells,  the  unguiform  bone,  the  vertical  portion  of  the 
palatine  bone,  of  the  superior  maxillary  bone,  and  the  inferior  turbi- 
nated bone,  on  the  outside  ;  all  these  bones,  as  we  have  already  remark- 
ed, belong  to  this  region  only  by  one  of  their  faces.  This  skeleton  is 
remarkable  for  its  thinness  and  resistance  above  on  the  inside,  and  on 
the  outside.  Farther,  we  find  here  the  pituitary  membrane,  which 
has  been  fully  described,  when  speaking  of  the  nostrils  ;  the  emissary 
veins,  and  the  ramifications  of  the  olfactory  nerve  belong  to  that  por- 
tion of  it  which  is  expanded  in  this  part. 

2.  Relations.  The  relations  need  scarcely  be  mentioned ;  the 
mucous  membrane  and  the  bones  exist  above  in  most  parts ;  on  the 
septum,  one  of  the  spheno-palatine  nerves,  termed  the  naso-palatine 
nerve,  descends  anteriorly  toward  the  anterior  palatine  foramen. 

Development.     This  presents  nothing  remarkable. 

Varieties.  Sometimes  more  than  three  turbinated  bones  exist ;  and 
we  have  found  five,  and  generally  four. 


68  TOPOGRAPHICAL  ANATOMY. 

Pathological  deductions  and  operations.  The  internal  olfactory 
region  is  entirely  deficient,  more  frequently  than  the  external.  Its 
skeleton  may  be  fractured  simply  by  blows  upon  the  nose,  or  by  a 
wounding  instrument  which  passes  through  the  mouth,  the  orbit,  &c. 
We  can  form  some  idea  of  the  severity  of  these  fractures,  if  situated  at 
the  upper  part.  In  coriza,  the  tumefaction  of  the  mucous  membrane 
contracts  the  cavity  which  is  already  rendered  narrow  by  the  turbi- 
nated  bones ;  hence  a  difficulty  of  breathing  through  the  nose ;  the 
swelling  of  the  valvular  fold  of  the  nasal  canal  under  the  same  cir- 
cumstances causes  a  flow  of  tears.  Foreign  bodies  if  introduced,  and 
placed  upon  the  floor,  glide  along  easily  and  fall  into  the  throat;  if 
they  are  pushed  upward,  they  become  fixed;  these  differences  are- 
explained  by  the  differences  in  the  capacity  of  the  cavity  in  these 
places.  Polypi  arise  most  frequently  in  this  portion  of  the  nostrils, 
especially  on  its  outer  wall ;  their  first  effect  is  to  flatten  the  turbinated 
bones  on  the  outside,  and  to  enlarge  the  cavity ;  the  hardest,  which 
are  fibrous,  dilate  the  parietes 'still  farther,  and  often  enlarge  one  of  the 
regions  at  the  expense  of  the  other.  We  have  observed  at  the  hospice 
Bicetre,  a  case  which  is,  as  far  as  we  know,  unique ;  a  fibrous  and 
vascular  polypus  had  dilated  the  spheno-palatine  foramen,  and  it  after- 
wards extended  through  this  opening  into  the  zygomatic  fossa.  The 
prominence  of  the  ascending  process  of  the  maxillary  bone  serves  as  a 
guide  for  inserting  the  catheter  into  the  nasal  canal ;  in  order  to  do 
this,  we  introduce  on  the  floor  of  the  nostrils  a  sound  which  is  pro- 
perly curved,  its  point  looking  outward ;  when  it  has  penetrated  an 
inch,  it  is  gently  withdrawn,  rubbing  the  point  against  the  outer  wall ; 
then  at  the  moment  it  is  arrested  by  the  prominence  mentioned,  the 
sound  is  depressed,  and  thus  carried  a  little  inward,  and  by  this  vibra- 
tory motion,  the  instrument  easily  penetrates  into  the  nasal  canal.  The 
relation  likewise  of  the  opening  with  the  eustachian  tube,  and  the 
posterior  opening  of  the  olfactory  canal,  serves  as  a  guide  for  introduc- 
ing an  instrument  into  the  tube ;  for  this  we  must  employ  a  sound 
which  is  curved  at  an  angle  of  one  hundred  and  thirty- five  degrees  5 
it  must  be  introduced  horizontally,  its  point  being  directed  downward, 
and  rubbing  against  the  floor  of  the  nostrils ;  and  when  it  has  come  to 
the  posterior  edge  of  this  floor,  which  can  be  determined  by  its  slipping 
into  the  pharynx,  it  should  be  rotated  outward  a  quarter  of  a  circle, 
and  at  the  same  time  it  is  made  to  vibrate  in  this  direction ;  it  then 
easily  penetrates  into  the  tube,  which  is  perceived  by  its  being  fixed. 


OP  THE  MOUTH.  69 

PARAGRAPH      SECOND. 

OF    THE    MOUTH. 

The  mouth  is  the  facial  portion  of  the  digestive  tube ;  it  is  an  oval 
cavity,  formed  by  several  distinct  regions ;  its  dimensions  may  be  esti- 
mated by  measuring  the  antero-posterior,  the  transverse,  and  the  ver- 
tical diameters,  which  vary  every  instant ;  these  varieties,  however, 
take  place  anteriorly ;  its  capacity  is  more  uniform  posteriorly. 

The  mouth  is  unmated  and  symmetrical,  situated  on  the  median 
line  of  the  body,  below  the  olfactory  region,  and  above  the  neck;  it  is 
bounded  on  the  sides  by  the  malar  regions ;  it  opens  anteriorly,  and 
into  the  pharynx  posteriorly ;  its  lateral  and  anterior  parts  are  the  only 
portions  of  the  external  surface  which  are  loose  and  cutaneous;  its 
inner  surface  is  mucous. 

In  this  portion  of  the  face,  we  must  study  the  buccal  cavity  and  its 
varieties ;  we  have  already  spoken  of  the  former,  which  belongs  to 
descriptive  .anatomy,  while  the  latter  make  a  part  of  the  anatomy  of 
the  regions. 

Structure.  The  buccal  parietes  have  several  things  in  their  struc- 
ture which  are  common;  a  skeleton  formed  by  the  inferior  and  superior 
maxillary  bones,  and  the  horizontal  portion  of  the  palatine  bones :  a 
mucous  membrane,  abundantly  provided  with  follicles,  and  covering 
the  buccal  glands ;  this  membrane  is  raised  in  certain  points  by  the 
ducts  of  the  salivary  glands,  which  perforate  it  obliquely,  after  passing 
a  certain  distance  below  it.*  It  is  doubled  outward  by  parts  which 
vary  in  almost  every  point,  and  should  be  examined  when  treating 
particularly  of  the  buccal  regions  ;  always  excepting  those  of  the  lower 
wall  of  the  mouth,  which  are  imbedded,  as  it  were,  in  the  neck,  and 
will  be  described  hereafter. 

All  the  buccal  arteries  come  from  two  sources,  the  facial  and  inter- 
nal maxillary  arteries;  the  veins  have  the  same  destination,  and  the 
lymphatic  vessels  go  to  the  sub-maxillary  ganglions.  The  nerves 
come  particularly  from  the  facial  and  from  the  fifth  pair  of  nerves ; 
the  nerves  of  some  organs  come  exclusively  from  the  latter,  but  most 
frequently  from  both. 

Development.  The  mouth  is  at  first  separated  on  the  median  line 
into  two  distinct  parts,  which  exist  for  a  long  time  on  its  skeleton,  and 
is  completed  by  their  uniting  in  the  middle,  which  union  is  particu- 
larly rapid  in  the  soft  parts.  The  upper  lip  and  the  palatine  arch 

*  In  regard  to  their  anatomical  arrangement  and  uses,  the  course  of  the  salivary  ducts 
through  the  buccal  parietes,  may  be  compared  to  that  of  the  ureters  in  the  parietes  of  the 
bladder. 


70  TOPOGRAPHICAL    ANATOMY. 

anteriorly,  do  not  form  an  exception  to  this  general  law  of  formation, 
as  we  shall  prove  hereafter. 

Varieties.  The  varieties  of  the  mouth  are  very  numerous ;  they 
affect  the  dimensions  of  its  anterior  opening  and  its  prominence  ;  in 
some  races,  this  prominence  is  very  remarkable,  particularly  in  the 
negro. 

Pathological  deductions  and  operations.  The  defects  in  the  deve- 
lopment are  here  very  important,  and  are  deduced  naturally  from  our 
remarks.  The  mouth  is  sometimes  deficient,  astomia  ;  in  this  case, 
we  often  find  on  the  sides  some  rudiments  of  two  lateral  portions 
which  would  have  formed  it.  Sometimes  the  development  is  arrested 
at  a  later  period,  the  whole  mouth  exists,  but  it  is  formed  of  two  pieces, 
which  are  distinct  superiorly. 

The  parietes  of  the  mouth  are  composed  of  the  following  regions  ; 
the  palatine,  the  palatal,  the  labial,  the  mental,  the  malar,  the  amyg- 
daloid, and  the  glosso-infra-hyoid  region,  which  belongs  to  the  neck, 
where  it  will  be  described. 

1.     PALATINE      REGION. 

This  unmated  and  symmetrical  region  forms  the  arch  of  the  mouth, 
and  is  united  with  the  floor  of  the  nostrils  ;  it  thus  separates  the  two 
median  cavities  of  the  face ;  it  is  continuous  anteriorly  with  the  upper 
lip,  posteriorly  with  the  velum  palati,  and  laterally  with  the  malar 
region.  These  latter  and  the  lip  are  separated  from  it  by  a  groove 
where  the  buccal  mucous  membrane. is  reflected. 

The  unattached  surface  of  this  region  is  mucous  :  it  is  concave  in 
every  direction,  particularly  in  the  transverse  ;  we  there  find  a  very 
apparent  median  raphe,  and  anteriorly  some  transverse  folds ;  its 
lateral  and  anterior  parts  are  formed  by  the  upper  alveolar  edge,  and 
contain  in  the  adult  sixteen  teeth. 

Structure.  — I.  Elements.  The  palatine  region  presents  a  great 
resistance,  which  depends  on  a  skeleton  situated  very  superficially, 
resting  on  the  pterygoid  process  of  the  sphenoid  bone,  and  formed  by 
the  horizontal  portions  of  the  superior  maxillary  and  palatine  bones. 
It  presents  a  median  and  a  transverse  suture,  the  anterior,  and  the  two 
posterior  palatine  foramina ;  finally,  the  teeth  should  also  be  counted  ; 
the  first  great  molar  tooth  corresponds  by  the  top  of  its  root;  and  of  its 
socket,  to  the  lowest  part  of  the  maxillary  sinus.  The  other  elements 
of  this  region  are,  the  mucous  membrane  covered  with  a  thick  epider- 
mis ;  a  very- dense  fibre-cellular  tissue ;  some  arteries  given  off  by  the 
posterior  palatine,  the  alveolar,  the  infra-orbitar  branch  of  the  internal 
maxillary,  and  the  superior  coronary  branch  of  the  facial  artery ;  some 
veins  which  follow  the  same  course ;  a  few  lymphatic  vessels,  and 


PALATINE   REGION.  71 

some  nerves  which  come  from  the  fifth  pair  only,*  by  the  palatine  and 
alveolar  twigs. 

2.  Relations.  The  relations  hardly  deserve  to  be  mentioned ;  we 
find  successively,  the  mucous  membrane,  adhering  intimately  to  the 
neck  of  each  tooth,  attached  to  the  skeleton  by  a  very  remarkable 
fibro-cellular  tissue,  in  the  centre  of  which  the  principal  palatine 
vessels  and  nerves  ramify  in  the  course  of  a  line  drawn  from  the 
posterior  to  the  anterior  palatine  foramen ;  the  middle  palatine  nerves 
and  vessels,  which  rest  on  the  inner  part  of  the  alveolar  edge,  and  on 
the  outside  of  it,  the  alveolar  vessels  and  nerves  posteriorly,  the  infra- 
orbitar  anteriorly,  and  finally,  beyond  this,  the  skeleton. 

Development.  The  median  raphe  explains  the  central  union  of 
the  two  sides  which  compose  this  region  in  the  fetus  ;  it  is  developed 
anteriorly,  as  the  upper  lip  ;  posteriorly  as  the  velum  palati ;  hence  we 
shall  mention  the  development  of  these  three  regions  collectively. 

Varieties.  In  the  very  young  embryo,  the  alveolar  edges  do  not 
exist  at  first ;  this  region  is  level  with  the  cheeks ;  as  the  teeth  are 
developed,  the  lateral  parts  become  prominent ;  at  first  the  transverse 
diameter  predominates,  the  antero-posterior  follows  the  formation  of  the 
teeth  ;  the  latter  by  their  development  have  a  remarkable  influence  on 
the  direction  of  the  pterygoid  process :  they  gradually  straighten  it, 
and  although  oblique  in  the  young  child,  it  becomes  perpendicular  in 
the  adult ;  it  again  becomes  oblique  in  the  old  man,  when  from  the  loss 
of  the  teeth,  the  alveolar  processes  are  restored  to  their  primitive 

state. 

Pathological  deductions  and  operations.  As  the  development  of 
this  region  has  been  referred  to  another  place,  we  shall  also  defer  the 
examination  of  its  deviations  of  formation,  which  depend  on  the  arrest 
of  its  development.  In  wounds,  a  hemorrhage  may  ensue  from  the 
vessels  of  the  palatine  arch,  which  it  is  difficult  to  arrest  by  a  ligature, 
on  account  of  the  density  of  the  tissue  in  which  the  vessels  are 
situated ;  a  density  which  renders  it  impossible  to  grasp  them  with 
forceps :  we  must  then  cauterize  them,  which  we  have  seen  done  by 
Dupuytren,  after  amputating  this  region  ;  this  skilful  operator  has 
removed  nearly  the  whole  palatine  arch  in  a  case  of  cancer.  Frac- 
tures of  this  part  have  but  slight  tendency  to  displacement;  the 
fragments  are  kept  in  place  very  firmly,  and.  are  acted  upon  by  no 
muscular  power.  Ulcerations  and  perforations  of  different  characters 
may  occur ;  the  latter  are  necessarily  attended  with  a  nasal  accent  and 
with  difficulty  of  deglutition.  Polypi  also  are  sometimes  situated  in  the 
gum,  epulis.  The, -maxillary  sinus  is  generally  opened  in  this  place, 

*  The  spheno-palatine,  and  even  the  nasso-palatine  ganglion,  discovered  by  H.  Cloquet, 
are  connected  with  the  fifth  pair. 


72  TOPOGRAPHICAL  ANATOMY. 

• 

at  the  alveolar  process  of  the  first,  great  molar  tooth  which  has  been 
previously  extracted,  as  this  is  the  most  sloping  part  of  the  sinus, 
which  will  be  described  when  speaking  of  the  malar  region  to  which 
it  belongs. 

« 

2.     PALATAL      REGION. 

The  arch  of  the  palate,  the  soft  palate  of  some  writers,  is  a  kind  of 
valve,  which,  by  its  elevation  or  depression,  may  alternately  leave  the 
pharynx  open  or  close  it ;  it  is  suspended  at  the  upper  part  of  the 
pharynx,  and  is  continuous  with  the  palatine  arch. 

Its  transverse  extent  has  a  relation  with  that  of  the  palate,  and-  its 
length  is  about  five  lines  :  its  form  is  quadrilateral;  it  has  two  mucous 
faces,  marked  on  the  median  line  by  the  raphe,  and  continuous,  one 
with  the  floor  of  the  olfactory  region,  the  other  with  the  palatine  arch ; 
one  of  its  edges,  the  superior,  adheres  to  this  ;  the  other,  the  inferior, 
is  arched  on  each  side,  and  presents  on  the  median  line,  the  uvula. 
Its  lateral  portions  are  embraced  by  the  pharynx,  and  give  rise  to  the 
two  pillars. 

Structure. — 1.  Elements.  The  solid  part  of  the  velum  palati  is 
formed  by  a  fibrous  layer,  belonging  to  the  two  circumflexus  palati 
muscles,  in  which  we  find  the  levator  palati  mollis,  the  glosso,  palato, 
and  pharyngo-staphylinus  muscles :  the  whole  of  the  latter  is  situated 
in  it,  while  the  others  only  terminate  there.  The  mucous  membrane 
contains  numerous  glandular  granulations,  particularly  near  its  loose 
edge.  The  arteries  come  from  the  superior  and  inferior  palatine  and 
pharyngeal  arteries ;  the  veins  follow  the  same  course  ;  the  lymphatic 
vessels  go  to  the  neck  at  the  angle  of  the  jaw.  The  nerves  are  given 
off  by  the  small  palatine  and  the  glosso-pharyngeal  nerve. 

2.  Relations.  From  behind  forward,  we  find  successively  the 
posterior  mucous  membrane,  a  dense  glandular  layer ;  the  palato- 
staphylinus  muscle  in  the  centre,  and  the  two  levator  palati  mollis 
muscles,  united  in  a  raphe  before  the  latter ;  the  aponeurosis  of  the 
circumflexus  palati  muscle,  the  extremities  of  the  glosso-staphylini 
muscles,  and  the  pharyngo-staphylini  muscles,  a  new  glandular  layer, 
and  the  anterior  mucous  membrane. 

Development..  In  the  following  article  we  shall  find  only  the  early 
development  of  the  velum  palati ;  this  part  is  very  short  in  the  child  j 
the  uvula,  particularly,  appears  as  a  mere  rudiment ;  on  the  contrary 
it  is  often  larger  in  the  adult  and  the  old  man, 

Varieties  and  uses.  The  velum  palati  is  subject  to  varieties  in  its 
directions,  connected  with  its  motions,  which  are  those  of  elevation, 
depression,  and  transverse  tension ;  the  object  of  some  of  these  motions 


LABIAL  REGION.  ,    73 

is  to  prevent  the  food  from  ascending  in  to  the  nasal  fossae  and 
eustachian  tubes,  during  deglutition,  while  the  others  tend  to  depress 
it  towards  the  lower  part  of  the  pharynx.  They  have  also  a  marked 
influence  on  the  voice. 

Pathological  deductions  and  operations.  We  shall  pass  over  the 
deviations  in  the  formation  of  the  velurn  palati  and  the  ingenious 
operation  for  its  fissure.  It  is  rarely  wounded ;  it  is  sometimes 
divided  to  facilitate  the  extraction  of  polypi  from  the  throat ;  this  can- 
not be  attended  with  severe  hemorrhage.  The  velum  palati  may  be 
partially  or  entirely  destroyed  by  ulcerations ;  the  uvula  may  be 
enlarged  by  a  hypertrophy  of  its  glandular  layer,  a  hypertrophy 
similar  to  that  of  the  amygdalae,  and  may,  by  tickling  the  base  of  the 
tongue,  produce  a  cough,  which  can  be  cured  only  by  its  amputation. 
The  abundance  of  the  mucous  glands  of  the  velum  palati,  explain 
those  membranous  secretions,  which  so  frequently  envelope  it  in 
children,  when  it  is  inflamed. 

3.     LABIAL      REGION. 

The  lips,  the  anterior  portion  of  the  buccal  parietes,  are  two  movable' 
bodies,  which  close  the  anterior  opening  of  the  mouth,  or  leave 
it  open,  as  occasion  may  require.  This  region  is  separated  inferiorly 
from  the  chin  by  the  mento-labial  groove,  and  from  the  malar  region 
on  the  side  by  the  naso-labial  depression,  which  forms  a  curve 
concave  anteriorly,  and  terminates  imperceptibly  towards  the  chin; 

There  are  two  lips,  an  upper  and  a  lower.  They  are  evidently 
perpendicular  to  the  horizon,  and  are  situated  directly  before  the 
upper  and  lower  gums,  with  which  they  are  united  by  a  mucous  fold^ 
termed  the  frenum.  They  unite  on  the  outside  to  form  the  commis- 
sures. They  have  two  faces ;  one  of  these  is  mucous,  posterior,  and 
concave,  which  presents  the  frenum,  and  is  rendered  uneven  by 
numerous  glands,  which  raise  its  internal  membrane ;  the  other  is 
cutaneous  and  anterior,  and  presents  at  the  upper  lip  a  median 
depression,  termed  the  infra-nasal,  which  is  covered  only  with  a  slight 
down  on  the  sides;  the  two  layers  are  directed  outward,  and  are 
covered  in  the  adult  with  hairs,  the  mustachios :  this  face  also  at  the 
lower  lip,  looks  a  little  downward  in  every  part :  it  is  depressed  on 
the  median  line,  and  in  this  point  only,  presents  a  small  tuft  of  beard,- 
in  the  male  adult.  The  loose  edge  of  the  lips  is  mucous :  the  skirt 
commences  on  the  outside,  following  a  line  which  curves  in  an 
opposite  direction  on  the  two  lips,  and  in  the  course  of  this  are 
situated  numerous  follicles,  the  labial,  particularly  near  the  commis- 
sures :  this  edge  is  red,  projects  on  the  median  line,  and  is  depressed 
10 


74  TOPOGRAPHICAL    ANATOMY. 

on  the  lower  lip :  it  presents  some  antero-posterior  grooves,  which 
become  very  distinct  when  we  attempt  to  contract  the  opening  of  the 
mouth,  and  by  the  mobility  of  which,  the  form  of  the  lips  can  be  very 
much  varied. 

Structure. — I.  Elements.  The  lips  are  formed  essentially  by  the 
skin  on  the  outside,  and  by  the  mucous  membrane  on  the  inside,  by  nu- 
merous follicles  and  glands ;  by  a  circular  muscle,  formed  principally 
by  the  termination  of  the  buccinator  muscle,  the  upper  fibres  of  which 
pass  into  the  lower  lip,  and  the  lower  fibres  into  the  upper  lip,  the 
central  fibres  being  arrested  at  the  commissure.  Besides,  the  depressor 
ali  nasse,  the  quadratus,  the  zygomaticus  major,  the  triangularis  and 
the  levator  ansfuli  oris  terminate  there  on  each  side ;  the  first  in  the 

O  ' 

upper  lip ;  the  second,  exclusively  in  the  lower  lip,  and  the  last  three  in 
the  commissure.  The  levator  muscles  of  the  upper  lip,  and  the  zygo- 
maticus minor  muscle,  do  not  come  as  far  as  this ;  they  are  bounded 
inferiorly,  as  we  have  frequently  demonstrated,  at  the  naso-labial  fis- 
sure, as  here  they  are  inserted  under  the  skin.  The  labial  arteries  come 
from  the  facial,  and  form  a  circle,  which  is  completed  on  the  outside 
by.  the  trunk  which  supplies  them :  they  thus  establish  an  easy  commu- 
nication between  the  two  facial  arteries.  We  also  find  in  the  lower  lip 
some  twigs  from  the  inferior  facial  artery  and  from  the  infraorbi- 
tar  artery  in  the  upper  lip.  The  veins  do  not  differ.  The  lymphatics 
all  proceed  to  the  submaxillary  ganglions.  The  nerves  come  from 
the  two  sources  already  mentioned,  the. facial  and  the  fifth  pair.  But 
little  cellular  tissue  exists,  and  this  is  very  soft :  it  contains  but  a  small 
portion  of  fat. 

2.  Relations.  The  relations  of  the  elements  of  the  lips  are  very 
simple :  at  first,  the  skin  which  adheres  very  firmly  and  on  which 
terminate  many  muscular  fibres;  a  muscular  layer  formed  by  the 
orbicularis  muscle,  on  the  loose  edge,  the  quadratus  below,  the  depres- 
sor alae  nasi  above;  at  the  commissure,  the  zygomaticus,  the  levator 
and  the  depressor  anguli  oris  united ;  they  conceal  the  anterior 
part  of  the  buccinator  muscle ;  more  deeply,  the  coronary  arteries  and 
the  mucous  membrane.  We  observe  that  the  superior  artery  always 
follows  the  edge  of  the  corresponding  lip,  while  the  inferior  artery  is 
situated  only  in  the  centre,  and  comes  there,  following  the  course  of  a 
line  oblique  from  this  point  to  the  lower  and  outer  part  of  this  lip. 
Whenever  a  coronary  artery  doe^s  not  exist  on  the  portion  of  the  edge 
of  the  lower  lip,  we  always  find  a  branch  which  anastomoses  with  it, 
and  which  comes  from  the  facial  or  from  the  superior  coronary  artery. 

Development.  The  lips  are  developed  at  a  late  period ;  from  their 
absence  in  the  early  periods  of  life,  the  oral  cavity  is  uninterruptedly 
continuous  with  the  anterior  plane  of  the  face  ;  when  they  appear,  they 


LABIAL  REGION.  75 

are  both  separated  on  the  median  line  ;  at  a  later  period,  the  raphe  is 
formed ;  the  upper  lip  as  we  shall  see  is  only  apparently  an  exception 
to  this  law.  Some  authors  think  that  when  the  lips  are  first  formed, 
they  are,  like  the  eyelids,  united  by  the  mucous  membrane. 

Simultaneous  development  of  the  upper  lip,  the  palatine  arch  and 
the  velum  palati.  The  upper  lip  and  the  velum  palati  are  moulded 
in  their  development  on  that  portion  of  the  palatine  arch  with  which 
they  are  directly  in  contact.  All  this  part  of  the  buccal  parietes  is 
formed  of  pieces  which  are.  united  in  the  median  raphe;  the  posterior 
portion  is  formed  of  two,  the  anterior  half  of  four ;  the  two  internal 
pieces  of  which  the  median  raphe  is  formed,  are  united  very  rapidly 
with  each  other,  and  at  a  later  period  with  each  lateral  segment. 
This  evolution  of  the  palatine  arch  is  evident;  the  same  is  true  of  the 
upper  lip,  in  which  the  pretended  single  point  was  at  first  double. 
We  have  dissected  a  fetus  where  the  upper  lip  was  cleft  on  the  median 
line.* 

Varieties.  The  lips  of  the  European  are  generally  situated  in  a 
perpendicular  plane ;  they  are  oblique,  and  remarkably  large,  in  the 
negro.  The  size  and  direction  of  the  lips  also  vary  in  the  same  races. 
The  upper  lip  particularly  is  remarkable  for  its  swelling  in  lymphatic 
subjects. 

In  a  young  child  the  lips  are  very  much  developed,  and  almost  cross 
each  other,  which  is  necessary  for  suckling.  When  the  teeth  are 
formed,  this  proportional  length  diminishes.  In  the  old  man,  they 
again  become  very  long  from  the  loss  of  the  teeth,  and  the  approxima- 
tion of  the  jaws,  they  project  forward  and  thus  give  the  face  a  peculiar 
expression,  and  hinder  mastication  and  articulation. 

Uses.  The  lips  possess  in  a  great  degree  the  power  of  contraction 
and  of  pouting. 

Pathological  deductions  and  operations.  The  lips  are  rarely 
absent ;  they  are  more  frequently  united  abnormally,  which  requires 
a  slight  operation ;  these  deviations  of  formation  are  explained  very 
readily  by  the  development  of  these  parts ;  this  is  true  also  of  their 
fissure,  which  constitutes  hare-lip,  this  is  rarely  seen  in  the  lower  lip, 
where  it  is  always- situated  in  the  centre;  on  the  contrary,  it  .is  fre- 
quent in  the  upper  lip,  and  there  is  then  a  simple  or  double  fissure ; 
when  it  is  simple,  it  is  seldom  situated  on  the  median  line,  which,  how- 
ever has  been  seen ;  it  was  then  caused  by  a  want  of  union  of  the  two 
median  segments  of  the  lip  •  it  is  much  more  frequently  lateral,  pro- 
duced by  the  want  of  union  of  the  double  median  segment  with  one 
of  the  lateral  segments.  In  the  second  case,  if  the  solution  of  continu- 

*  In  the  hare  and  in  all  the  gnawers,  the  upper  lip  is  cleft  on  the  median  line,  and  we  can- 
not assert  that  in  them  the  development  varies  from  what  we  have  stated. 


76  TOPOGRAPHICAL  ANATOMY. 

ity  be  double,  there  may  be  a  median  and  a  lateral  fissure ;  but  the 
two  are  generally  lateral,  on  account  of  the  too  rapid  union  of  the 
two  small  median  points.  This  division  may  be  confined  to  the  lip, 
or'it  may  extend  to  the  palate,  rarely  upon  the  median  line,  and  for 
the  same  reason.  Sometimes  one,  and  sometimes  two  divisions  exist 
at  the  anterior  part  of  the  palate.  In  the  latter  case,  it  generally 
becomes  simple,  when  it  extends  to  the  posterior  part ;  but  as  the  fis- 
sure anteriorly  may  affect  only  the  lip,  or  this  and  the  anterior  part  of 
the  palate,  so  too,  it  often  affects  the  velum  palati  posteriorly,  or  both 
this  and  the  posterior  part  of  the  palatine  arch.  In  these  two  cases, 
but  one  fissure  exists,  and  this  is  situated  directly  in  the  centre.  The 
effect  of  the  development  of  the  arch  of  the  palate,  on  that  of  the  lip- 
and  the  velum  palati  is  such,  that  the  latter  are  moulded  anteriorly 
and  posteriorly  on  the  former, :  this  fact  has  been  demonstrated  in  the 
normal  formation,  but  after  the  operation  for  hare-lip,  we  have  often 
noticed  an  opposite  action  of  the  lip  on  the  divided  palatine  arch. 
The  operation  of  staphyloraphy  invented  in  our  times,  and  almost 
simultaneously  by  two  of  the  finest  surgeons  in  Europe,  Ronx  in 
France,  and  Greefe  at  Berlin,  would  doubtless  furnish  an  opportunity 
for  observing  the  same  phenomena  at  the  posterior  part  of  the  palatine 
arch.  Unfortunately,  however,  as  Roux  has  observed,  staphyir  raphy 
succeeds  with  difficulty,  when  the  palatine  arch  is  divided ;  this 
celebrated  surgeon  also  proposes  to  attempt  the  union  of  the  palate, 
either  by  making  a  lateral  pressure  on  the  superior  dental  arches,  or 
by  removing  a  portion  of  the  soft  tissue  of  the  palatine  region,  on  each 
side,  and  uniting  them  on  the  median  line.  This  plan  certainly  seems 
Practicable,  but  we  fear  it  will  fail,  because  the  superior  dental  arches 
resting  posteriorly  on  the  pterygoid  processes,  do  not  seem  capable  of 
approximating  by  yielding  to  a  lateral  pressure,  and  also  because  the 
submucous  tissue  of  the  palatine  arch  is  very  dense,  and  might  not 
admit  the  extension  necessary  to  bring  it  to  the  point  of  contact,  below 
the  separation  of  the  bone.  The  palatine  arch  together  with  the  lip 
and  the  velum  palati  may  be  entirely  deficient :  sometimes  there  is  a 
broad  median  separation,  which  unites  the  mouth  and  the  olfactory 
region ;  then  the  apparently  unmated  anterior  point  of  the  lip  and  of 
the  palate  is  not  formed ;  we  have  observed  that  this  defect  generally 
co-exists  with  the  absence  of  the  olfactory  nerve. 

Wounds  of  the  lips,  notwithstanding  the  reasoning  of  Louis,  cannot 
be  kept  in  place,  and  consequently  cured  without  deformity,  except  by 
the  twisted  suture.  This  depends  entirely  on  the  very  great  contrac- 
tility in  the  transverse  direction  of  these  parts ;  their  vascularity 
•explains  the  frequent  appearance  of  erectile  tumors  here. 


MENTAL  REGION.  77 


4.      MENTAL      REGION. 

The  mental  region,  a  small  portion  of  the  huccal  parietes,  is  com- 
posed of  the  central  portion  of  the  lower  maxillary  bone,  and  of  the 
parts  which  rest  upon  it  anteriorly  ;  its  limits  are  well  defined.  It  is 
united  posteriorly  to  the  floor  of  the  mouth  ;  it  forms  anteriorly  a 
prominence  which  is  generally  bilobate,  and  on  which  the  raphe  is 
well  marked :  the  latter  is  always  covered  in  adult  males  with  coarse 
hair,  and  is  directed  a  little  upward. 

Structure.  —  I.  Elements.  The  part  of  the  inferior  maxillary  bone 
which  belongs  to  this  small  region,  presents  the  symphysis,  the  mental 
process,  the  mental  fossae,  and  posteriorly  the  genial  processes.  The 
depressor  alaa  nasi  muscle,  the  quadratus  menti,  some  fibres  of  the 
plalysma :  the  skin,  a  compact  cellular  and  adipose  tissue,  some  arteries 
which  come  from  the  inferior  dental,  and  the  submental  arteries,  some 
similar  veins,  some  trivial  lymphatic  vessels,  some  nerves  from  the 
facial  and  the  fifth  pair,  are  the  other  elements  of  this  region. 

2.  Relations.  All  these  parts  are  arranged  in  the  following  order  : 
the  skin,  on  which  are  placed  the  fibres  of  the  depressor  alee  nasi 
muscle,  thus  rendering  it  more  fixed  ;  a  dense  cellulo-fatty  layer :  a 
muscular  layer  formed  by  the  two  quadrati  united  on  the  median  line, 
which  layer  is  traversed  perpendicularly  by  the  fibres  of  the  depressor 
alae  nasi :  next  comes  the  last  named  muscle,  which  is  surrounded  by 
a  looser  tissue  of  vessels  and  nerves  ;  the  whole  rests  on  the  maxillary 
bone. 

Development.  The  chin  apparently  is  at  first  cjeft :  in  children 
and  in  old  men  it  is  very  prominent  and  is  curved  upward  :  in  the 
adult  it  is  much  less  so. 

Varieties.  This  region  presents  many  individual  varieties  which 
are  of  no  importance. 

Pathological  deductions  and  operations.  Wounds  of  the  chin  are 
common,  but  fortunately  they  are  not  very  serious,  excepting  how- 
ever its  fractures.  In  fractures  of  the  jaw,  and  particularly  in  those 
produced  by  a  counterblow,  the  fracturing  force  acts  through  the  chin ; 
the  chin  has  sometimes  been  paralyzed  after  these  injuries,  when  they 
were  complicated  with  a  laceration  of  the  dental  nerve.  The  organic 
affections  of  this  region  are  usually  consequent  upon  those  of  the 
lower  lip :  they  sometimes  require  its  removal,  and  particularly  that  of 
its  skeleton  :  Uupuytren  and  Delpech,  have  been  very  successful  with 
it :  Graefe  of  Berlin  has  gone  still  farther,  and  has  had  the  boldness  to 
extirpate  the  whole  maxillary  bone.  The  amputation  of  the  bony 
part  of  the  chin  requires  the  previous  removal  of  the  soft  parts  of  the 


73  TOPOGRAPHICAL  ANATOMY. 

floor  of  the  mouth,  except  in  some  cases  where  the  superficial  part  of 
the  bone  only  is  to  be  removed.  The  lateral  sections  of  the  jaw  must 
always  be  made  obliquely  from  behind  forward,  and  from  without 
inward,  in  order  to  afford  the  least  possible  chance  of  separation 
between  the  fragments,  and  more  opportunities  for  the  formation  of  an 
intermediate  fibrous  or  cartilaginous  substance. 

5.      MALAR     REGION. 

The  malar  region  forms  the  lateral  wall  of  the  mouth ;  its  bounds 
on  the  outside  are  less  exact  than  on  the  inside.  In  the  first  direction, 
the  lower  and  posterior  edges  of  the  lower  jaw  separate  it  from  the 
parotid  and  supra-hyoid  regions  ;  the  zygomatic  arch,  and  the  base  of 
the  orbit  above,  separate  it  from  the  temporal  and  inferior  palpebral 
regions;  while  forward,  the  curved  naso-labial  groove,  which  we 
have  already  mentioned,  distinguishes  it  from  the  lips. 

The  malar  region  is  quadrilateral,  and  its  surface  is  much  greater 
than  its  thickness  ;  in  this  latter  dimension,  the  posterior  part  exceeds 
the  anterior.  Farther,  it  presents  two  faces ;  one  is  cutaneous,  the 
other  mucous;  the  first  is  generally  convex  and  downy;  its  most 
prominent  point  corresponds  to  the  malar  bone  and  forms  the  cheek, 
which  is  remarkable  for  the  fineness  and  beauty  of  the  skin  which 
covers  it;  at  its  central  part  there  is  often  a  depression  which  varies 
in  depth ;  we  must  distinguish  it.  from  another  which  is  situated 
anteriorly,  and  which  females  consider  a  beauty.  The  mucous  or 
internal  face  is  smooth  in  most  of  its  extent ;  it  is  attached  only  above 
and  below.  At  the  place  where  this  adhesion  commences,  there  is  a 
groove  which  is  continuous  with  that  behind  the  lips,  and  which  may 
be  termed  the  genio-maxillary  groove.  This  face  of  the  malar  region 
presents  in  its  loose  portion  some  prominences  which  belong  to  the 
buccal  glands ;  the  opening  of  the  duct  of  Sterio,  which  is  directed 
obliquely  forward  and  inward,  and  corresponds  with  the  level  of  the 
second  upper  great  molar  tooth,  three  lines  from  the  upper  genio-maxil- 
lary groove ;  a  depression  opposite  the  first  of  these  on  the  outside, 
which  depression  is  bounded  posteriorly  by  a  mucous  fold  which 
extends  between  the  upper  and  lower  alveolar  edges,  and  is  situated 
below  the  ramus  of  the  jaw. 

Structure. —  1.  Elements.  The  structure  of  the  malar  region  is 
very  complex :  it  is  composed  of  very  different  elements.  Its  skeleton 
is  formed  by  half  of  the  lower  maxillary  bone,  the  external  part  of  the 
upper  maxillary  bone,  and  the  malar  bone  ;  the  first  is  grooved  below 
by  the  inferior  dental  canal ;  it  is  partly  opened  at  the  mental  foramen, 
and  communicates  with  the  base  of  the  alveolar  processes  by  small 


MALAR  REGION.  79 

channels ;  the  second  presents  on  its  surface  the  canine  fossa,  the 
infra-orbitar  foramen,  and  internally  the  maxillary  sinus,  a  pyramidal 
cavity,  which  corresponds  anteriorly  to  the  preceding  fossa ;  above 
to  the  orbit,  below  to  the  summit  of  the  alveolar  processes  of  the  molar 
teeth,  and  particularly  those  of  the  third  and  fourth,  which  sustain 
this  wall ;  posteriorly  to  the  malar  tuberosity,  inward  to  the  internal 
nasal  region  and  particularly  to  the  nasal  canal  forward,  backward  to 
the  middle  meatus  in  a  point  where  it  is  opened  as  has  already  been 
mentioned. 

The  masseter,  the  pterygoideus  interims,  and  the  buccinator  muscles 
are  the  largest  in  this  region ;  the  zygomaticus  major,  the  triangu- 
laris,  some  fibres  of  the  platysma,  of  the  orbicularis  palpebrarum^ 
and  of  the  levator  anguli  oris  muscles,  the  levator  labii  superioris 
proprius,  and  the  zygomaticus  minor  muscles,  are  confined  to  the 
malar  region,  and  terminate  in  the  curved  nasolabial  groove ;  the 
malar  region  is  strengthened  in  its  weakest  part,  at  the  buccinator 
muscle,  by  an  aponeurosis  which  has  not  hitherto  been  described; 
this  layer,  which  may  be  termed  the  genial,  is  formed  of  one  fold 
anteriorly,  and  of  two  posteriorly;  one  of  them  rests  directly  on  the 
buccinator,  is  generally  considered  as  an  expansion  of  the  external 
membrane  of  the  duct  of  Steno,  and  is  very  distinct  from  the  pharyngo- 
buccal  aponeurosis,  the  description  of  which  does  not  belong  to  our 
subject ;  the  other  separates  from  the  buccinator  muscle;  and  is 
inserted  on  the  anterior  edge  of  the  ramus  of  the  lower  maxillary 
bone ;  two  anterior  prolongations  of  the  parotid  gland  proceed,  one 
superficially,  the  other  deeply  into  the  malar  region ;  the  first,  the 
larger,  often  forms  a  distinct  lobe  of  the  gland,  and  is  furnished  with  a 
secretory  duct  which  goes  to  the  duct  of  Steno  ;  the  second  is  situated 
between  the  ramus  of  the  jaw  and  the  pterygoideus  internus  muscle. 
This  arrangement  of  the  parotid  gland,  in  respect  to  the  ramus  of  the 
jaw,  resembles  that  of  the  sub-maxillary  gland  on  the  loose  edge  of  the 
mylo-hyoideus  muscle.  The  parotid  canal  passes  through  the  malar 
region  horizontally  from  behind  forward,  at  the  union  of  the  upper 
with  its  two  lower  thirds,  and  then  terminates  at  the  outer  part  of  the 
middle  depression  mentioned  above  ;  it  forms  also  in  front  of  the 
masseter  muscle,  a  curve  convex  anteriorly,  it  passes  obliquely  through 
the  different  layers  of  this  region,  appears  under  the  mucous  mem- 
brane, and  perforates  it  at  the  place  mentioned.  The  malar  arteries 
may  be  divided  into  the  superficial  and  deep  :  the  first  come  from  the 
facial  and  from  the  transverse  facial  artery,  the  second  are  given  off 
by  the  internal  maxillary,  and  particularly  by  its  infra-orbitar,  alveolar, 
masseteric,  pterygoid,  buccal,  and  inferior  dental  branches ;  all  anas- 
tomose frequently  with  each  other,  and  communicate  with  those  of  the 


• 
30  TOPOGRAPHICAL   ANATOMY. 

- 

orbit.     The  veins  follow  the  course  of  the  arteries,  and  differ  from 

them  in  having  fewer  curves ;  the  superficial  and  the  deep  veins 
communicate  by  broad  branches,  which  are  often  so  much  developed 
that  they  may  be  considered  as  trunks,  which  unite  and  form  the 
anterior  internal  maxillary  vein  of  Meckel.  The  lymphatic  vessels  of 
the  malar  region  are  divided  between  the  parotid,  the  sub-maxillary, 
and  the  deep  cervical  ganglions.  The  nerves  come  exclusively  from 
the  two  sources  mentioned  when  speaking  of  the  mouth,  the  facial 
nerve  and  the  fifth  pair  ;  the  filaments  of  the  first  have  a  transverse  or 
oblique  direction  ;  some  are  buccal,  the  others  malar ;  the  filaments  of 
the  second  are  perpendicular  or  oblique,  the  buccal,  the  masseteric, 
and  the  dental  branch  of  the  inferior  maxillary  nerve,  the  infra-orbita* 
and  the  alveolar  branches  of  the  superior  orbitar  :  the  lingual  and  the 
superficial  temporal  nerve  only  pass  through  this  region.  The  skin 
and  the  mucous  membrane  present  nothing  more  than  what  we  have 
stated ;  the  first  is  remarkable  for  its  fineness  and  for  the  vascular 
net-work  which  it  contains.  But  little  cellular  tissue  exists  anteriorly; 
the  contrary  is  true  posteriorly ;  so  too  with  the  adipose  tissue  which 
is  divided  by  the  genial  aponeurosis  into  two  distinct  masses,  one  of 
which  is  superficial,  the  other  deep;  they  have  opposite  states  of 
development. 

Relations.  The  relations  of  the  malar  region  are  very  complex 
and  important  j  in  order  to  mention  them  distinctly,  they  must  be 
traced  successively  in  three  parts,  the  cheek,  the  masseteric,  and  the 
inter-maxillary  portion. 

1.  Check.  The  finest,  and  most  vascular  skin  of  the  cheek  forms 
a  first  layer,  and  rests  on  a  small  quantity  of  cellulo-fatty  tissue  ;  next 
comes  a  prolongation  of  the  orbicularis  palpebrarum  muscle,  which 
conceals  posteriorly,  the  origin  of  the  zygomaticus  major,  and  anteriorly 
that  of  the  zygomaticus  minor  muscle,  inferiorly  the  transverse  facial 
artery  and  also  some  malar  filaments  of  the  facial  nerve  ;  these  filaments 
are  distributed  in  the  preceding  muscles,  particularly  the  zygomatici, 
and  anastomose  with  some  minute  ramifications  of  the  fifth  pair  which 
emerge  from  the  malar  foramina* 

In  the  masseteric  portion,  there  is  more  cellulo-fatty  tissue  directly 
under  the  skin  in  the  cheek;  we  also  find  there  some  fibres  of  the  platys- 
«  ma  myoides  muscle  ;  a  layer  is  then  distinctly  formed,  first,  by  the  ante- 
rior edge  of  the  parotid  gland,  under  which  we  see  the  buccal  filaments 
of  the  facial  nerve ;  second,  by  the  duct  of  Steno,  which  has  a  transverse 
direction  below  the  prominent  edge  of  the  malar  bone,  and  which  is  co- 
vered by  a  large  filament  of  the  facial  nerve,  and  by  the  distinct  lobe  of 
the  parotid  gland,  the  small  parotid  gland  of  some  writers ;  third,  above, 
by  the  upper  extremity  of  the  zygomaticus  major  muscle  ;  more  deeply 

I, 


'    •       fc 

MALAR  REGION.  81 

appears  the  masseter  muscle,  concealing-  the  masseteric  vessels  and 
nerves,  the  ramus  of  the  jaw,  its  coronoid  process,  the  neck  of  its  con- 
dyle  and  thesygmoid  fissure,  on  which  the  deep  masseteric  vessels  and 
nerves  rest.  Under  the  bone  we  find,  directly  below,  the  lingual  nerve, 
the  myloid  filament  of  the  inferior  dental  nerve,  and  the  pterygoideus 
interims  or  the  masseter  muscle ;  this  latter  is  separated  from  the  maxil- 
lary bone,  which  is  above  it,  by  a  space,  which  contains,  the  internal 
maxillary  artery  and  its  first  branches,  the  inferior  dental  and  the  super- 
ficial temporal  nerves  at  their  origin,  the  internal  lateral  .ligament  of 
the  temporo-maxillary  articulation,  this  latter  separating  the  parts 
we  have  named  from  the  lingual  nerve  of  the  fifth  pair. 

3.  Intermaxillary  portion.  When  we  have  removed  from  this  space, 
the  skin,  the  subcutaneous  cellule-fatty  tissue,  and  the  filaments  of  the 
facial  nerve  which  are  there  distributed  in  every  part,  we  discover 
successively;  above,  the  orbicularis  palpebrarum  muscle;  the  facial 
vessels,  the  vein  being  a  little  on  the  outside  of  the  artery ;  the  zygoma- 
ticus  minor  and  the  proper  levator  of  the  upper  lip  ;  the  infraorbitar 
vessels  and  nerves,  the  levator  anguli  oris  muscle  and  the  canine  fossa ; 
the  upper  maxillary  bone  and  the  antrum  Highmorianum,  containing  in 
its  anterior  wall  the  anterior  dental  vessels  and  nerve  ;  in  the  centre,  the 
zygomaticus  major  muscle  proceeding  towards  the  commissure,  on  the 
outside  of  which  it  unites  with  the  levator  and  the  depressor  anguli  oris 
muscles,  covering  directly  the  facial  artery  and  also  the  buccinator 
muscle,  from  which,  however,"  it  is  separated  posteriorly  by  some  adipose 
tissue  in  which  the  duct  of  Steno  penetrates  transversely  at  the  upper 
part ;  second,  by  the  facial  vein,  which  ascends  near  the  masseter 
muscle,  and  is  at  least  one  inch  distant  from  the  facial  artery ;  third, 
by  the  genial  aponeurosis,  which  is  single  forward,  and  contains 
posteriorly,  between  its  layers,  some  adipose  tissue  ;  finally,  by  a  great 
number  of  malar  glands,  the  buccinator  muscle  forming  a  very  simple 
layer,  below  which  the  mucous  membrane  is  seen ;  below,  the  facial 
vessels,  the  vein  always  on  the  outside  of  the  artery,  both  resting 
directly  on  the  bone,  before  the  masseter  muscle,  and  behind  the  de- 
pressor labii  inferioris  and  the  quadratus  muscle  ;  finally,  this  last  con- 
ceals the  maxillary  bone,  the  mental  foramen,  and  also  the  mental 
vessels  and  nerves. 

Development.  The  malar  regions  are  very  slightly  developed 
from  before  backwards  in  the  embryo ;  they  are  at  first  deficient ; 
during  fetal  life  and  early  infancy,  they  bulge  out  very  much,  which 
depends  on  the  absence  of  the  teeth  which  admits  the  approximation 
of  the  jaws,  and  on  the  considerable  development  of  the  fat  on  the  outside 
of  the  aponeurosis.  Bichat  has  shown  that  this  fat  forms  a  rounded 
mass  which  is  very  remarkable,  and.  as  it  were,  lipomatous.  This 
11 


82  TOPOGRAPHICAL    ANATOMY. 

fulness  continues  for  a  long  time,  although  it  gradually  diminishes ; 
in  the  adult,  it  is  replaced  by  the  external  depression  which  has  been 
mentioned ;  the  absorption  of  the  superficial  fat,  while  the  deep  seated 
fat  remains,  accounts  sufficiently  for  this  change  in  the  external  form. 
In  the  old  man,  the  fat  diminishes,  although  the  cheek  does  not  fall  in 
proportionally,  which  depends  on  the  approximation  of  the  jaws  by 
the  loss  of  the  teeth  :  this  approximation  throws  the  cheeks  outward, 
and  leaves  them  very  flaccid.  In  the  fetus,  the  malar  region  is  trian- 
gular :  its  parotid  edge  blends  with  the  lower  edge ;  when  the  teeth 
are  developed,  it  gradually  assumes  a  quadrilateral  form,  while  its 
lower  and  posterior  angle  approaches  a  right  angle.  In  the  old  man, 
the  cheek  again  becomes  triangular,  even  when  all  the  teeth  are  lost. 
Let  us  carefully  remark  this  influence  of  the  teeth  on  the  angle  of  the 
cheek ;  this  physiological  fact  has  served  for  the  base  of  some  opera- 
tions. After  the  period  of  puberty,  the  hairs  of  the  beard  appear  on 
the  malar  region  of  the  man,  and  in  the  two  sexes,  this  assumes  its 
agreeable  color.  This  color  of  the  cheek  disappears  in  the  adult  age  ; 
but  a  violet  and  striated  redness  of  the  small  vessels  succeeds,  which 
Beclard  thinks  is  owing  to  the  dilatation  of  the  capillary  veins.  In 
children,  the  maxillary  sinus  scarcely  exists  ;  it  gradually  forms  as  age 
advances,  and  often  extends  into  the  malar  portion  ;  its  parietes  become 
thin,  and,  as  it  were,  transparent. 

Varieties.  In  the  female,  the  malar  bones  and  the  masseteric 
portion  of  the  region  are  less  prominent  than  in  the  male ;  the  superfi- 
cial fat  is  more  abundant ;  hence  a  more  graceful  roundness,  which  is 
hardly  interrupted  by  a  slight  groove  anteriorly ;  the  skin  is  covered 
with  a  slight  down,  the  whiteness  of  which  contrasts  in  some  parts  with 
the  freshness  and  brilliancy  of  its  color  in  others. 

The  zygomaticus  minor  muscle  is  often  deficient,  and  the  orbicula- 
ris  palpebrarum  muscle  sometimes  descends  very  low ;  sometimes  the 
masseteric  artery  does  not  exist,  and  is  replaced  by  the  enlarged  twigs 
of  the  transverse  facial  artery. 

Physiology.  The  malar  region  forms  one  of  the  buccal  parietes ; 
for  this  purpose  it  has  a  proper  resistance,  derived  from  different  layers, 
particularly  from  its  aponeurosis ;  it  also  executes  two  kinds  of 
motions,  some  belonging  to  the  functions  of  digestion,  the  others  to 
those  of  respiration.  Charles  Bell  and  Shaw  have  proved  by  their  experi- 
ments, that  the  first  depend  on  the  nerve  of  the  fifth  pair,  and  the 
second  on  the  facial  nerve  ;  a  noble  discovery,  which  has  thrown  great 
light  on  the  physiology  of  the  cheek.  The  motions  of  the  cheek 
which  are  connected  with  digestion  are,  first,  those  which  have  for 
their  object  the  reception  of  solid  or  liquid  food;  second,  those  of 
mastication,  in  which  the  buccinator  muscles  push  the  food  between 


MALAR  REGION.  83 

the  jaws,  which  are  brought  together  and  rubbed  against  each  other ; 
third,  those  of  deglutition,  and  fourth,  finally,  those  by  which  we 
manifest  the  want  or  the  desire  of  taking  nourishment.     The  respira- 
tory motions  of  the  cheeks  are  manifested  in  gaping,  in  blowing,  and 
in  the  passions  which  affect  the  whole  respiratory  system,  and  particu- 
larly the  malar  region.     These  last  modify  extremely  the  expression 
of  the  face  ;  the  cheek  then  becomes  the  mirror  of  the  soul ;  when  the 
feelings  are  gay,  it  is  drawn  upward  and  outward ;  but  when  the  mind 
is  sad,  obliquely  downward.     In  these  motions,  the  anterior  portion 
is    always    drawn   toward  the    other   parts,   the   curved  naso-labial 
groove  being  the  true  moveable  point ;  the  insertion  of  several  small 
facial  muscles  near  it,  satisfactorily  explains  these  phenomena.     When 
the  impressions  received  are  slight  and  trivial,  they  leave  no  trace 
upon  the  cheek;  but  when  serious,  they  produce  deep  and  permanent 
grooves ;  hence  two  characters,  by  which  the  moralist  and  physician 
may  immediately  recognise  the  mildness  or  the  violence  of  the  passions. 
In  the  young  child,  the  cheek  which  at  nearly  the  same  instant  is  alter- 
nately moistened  with  a  tear  and  decked  with  a  smile,  preserves  in 
the  healthy  state  that  roundness  which  marks  this  happy  age.     In  the 
adult,  on  the  contrary,  the  cheek  always  presents  more  or  less  distinct 
wrinkles ;  this  arrangement  is  still  more  apparent  in  old  age,  because 
the  old  man  is  cross  and  fretful ;  in  the  old  man,  however,  we  must 
not  consider  as  marks  of  the  passions,  those  wrinkles  caused,  as  has 
been  said  above,  by  the  approximation  of  the  jaws.     Lavater  thinks 
that  the  sentiment  of  the  physiognomy  is  situated  in  the  chepks;  as  a 
proof  of  this,  we  have  only  to  examine  comparatively,  the  base  and 
jealous  man,  with  him  who  is  generous  and  noble.     The  color  of  the 
cheeks  also  varies  much  in  the  passions  ;  it  is  important  to  determine 
the  physiological  origin  of  these  changes  of  color.     Sometimes,  as  in 
fear  or  envy,  the  cheek  is  pale  and  colorless ;  sometimes,  as  in  love  and 
anger,  it  is  uncommonly  red.     These  different  states  result  from  the 
immediate  and  certain  action  of  the  passions  upon  the  circulatory  and 
respiratory  systems,  which  are  influenced  reciprocally  so  much  as  to 
be  always  excited  simultaneously.     The  changes  in  the  cheek  which 
affect  the  expression,  like  the  respiratory  motions,  depend  particularly 
on  the  influence  of  the  facial  nerve ;  children  and  females,  in  whom 
the  nervous  system  is  generally  more  susceptible  to  impressions,  also 
present  in  the  greatest  degree  these  more  or  less  transient  modifications 
of  the  cheek. 

Pathological  deductions  and  operations.  The  cheeks  are  very 
much  changed  in  diseases,  and  the  physician  must  carefully  attend  to 
these  changes  ;  but  this  will  be  difficult  unless  he  continually  bears  in 
mind  our  views  of  the  healthy  state  of  this  region.  These  modifica- 


84  TOPOGRAPHICAL  ANATOMY. 

tions  constitute  the  morbid  expressions  of  the  face,  the  best  description 
of  which  is  imperfect,  and  which  should  be  studied  at  the  bedside  of 
the  patient ;  all  good  physicians  admit,  that  this  study  can  furnish 
signs  of  internal  diseases,  which,  if  not  certain,  are  at  least  very  advan- 
tageous. Those  who  neglect  or  seek  to  ridicule  this  mode  of  investi- 
gation, prove  only  one  thing,  that  they  study  pathology  without  a 
proper  knowledge  of  anatomy  and  physiology,  upon  which  the  former 
is  founded. 

The  action  of  stimulants  upon  the  digestive  and  respiratory 
systems  are,  as  we  have  seen,  even  in  the  healthy  state,  marked  upon 
the  cheek  by  peculiar  expressions.  Being  stronger  in  the  morbid 
state,  ought  they  not  to  cause  a  similar  but  forced  expression  ?  The 
shrinking  of  the  face,  and  particularly  of  the  cheek,  in  abdominal 
affections,  the  bright  color  of  the  cheek  in  the  thoracic  affections  &c., 
all  prove  the  affirmative  of  this  question.  The  morbid  expression  of 
the  face,  then,  is  extremely  useful,  and  often  the  only  guide  of  the 
physician  in  a  very  young  child,  who  can  tell  nothing  in  regard  to  its 
sufferings  ;  happily  also,  the  cheek,  at  this  age,  has  not  been  altered  by 
the  passions,  so  that  its  morbid  changes  represent  exactly  the  diseases 
of  the  internal  organs;  in  the  adult  and  the  old  man,  the  conditions 
of  the  healthy  state  are  entirely  changed,  and  render  the  morbid 
expressions  of  the  face  more  difficult  of  observation,  and  less  impor- 
tant, although,  in  many  cases,  they  are  extremely  useful  to  the 
enlightened  physician. 

Wounds  of  the  malar  region  may  be  complicated  with  a  hemor- 
rhage which  may  come  particularly  from  the  facial  artery;-  this 
accident  is  of  little  importance,  because  the  vessels  of  the  malar  region 
are  easily  tied.  Farther,  the  arteries  of  this  region  are  so  numerous, 
and  open  there  by  so  many  points,  that  the  edges  of  the  wounds  bleed 
in  every  part.  When  the  wounding  instrument  is  carried  backward 
on  the  masseteric  portion,  the  canal  of  Steno  may  be  affected;,  the  lesion 
of  this  in  front  of  the  masseter  muscle  is  more  difficult,  because  it  is 
situated  more  deeply  there:  we  remark,  however,  that  in  the  first  point, 
this  canal  being  situated  under  the  projecting  edge  of  the  malar  bone 
and  the  zygomatic  arch,  has  often  been  protected  by  it.  A  Gendarme 
whom  we  attended,  presented  a  remarkable  instance  of  this  fact:  he  had 
received  in  a  duel  a  sabre  wound,  which  was  vertical,  penetrating 
above  on  the  malar  bone,  and  below  into  the  masseter  muscle,  which 
was  injured ;  the  salivary  duct,  however,  was  only  crowded  back,  and 
the  wound  cicatrized  promptly  without  the  formation  of  a  fistula. 
Nevertheless,  -the  wounded  are  often  less  fortunate,  the  wound  is  then 
more  serious,  and  a  fistula  will  be  formed  if  the  patient  does  not 
receive  medical  assistance.  Percy  regards  this  unfortunate  result 


MALAR  REGION.  •          85 

as  rare,  founding  his  opinion  upon  the  great  number  of  wounds  of  the 
cheeks  which  are  perfectly  cured.  Boyer  is  of  an  opposite  opinion, 
which  we  can  adopt  much  more  readily,  as  the  fact  which  has  been 
mentioned,  and  the  anatomical  arrangement  of  the.  canal  of  Steno, 
establish,  that  in  most  of  wounds  cured  without  a  fistula,  according 
to  Percy's  remark,  there  was  no  injury  of  the  excretory  duct.  The 
fistulse  caused  by  these  wounds  may  be  external  or  internal : 
the  first  are  the  only  ones  to  be  feared ;  the  second  are  attended 
with  no  inconvenience  ;  they  also  point  out  to  the  surgeon  the  mode 
of  preventing  or  curing  the  others.  Does  a  wound  affect  the  whole 
cheek  ?  its  lips  are  separated  inward,  while  they  unite  externally.  If 
the  wound,  on  the  contrary,  or  the  fistula,  be  only  external,  we  make 
an  incision  on  the  inside  of  the  mouth  with  a  bistoury,  and  the  same 
course  is  adopted,  as  in  the  first  case,  for  the  internal  dilatation,  and  the 
union  of  the  skin.*  Lewis  and  Morand  have  proposed  to  introduce  an 
instrument  intd  the  duct  of  Steno  to  dilate  it  in  some  cases :  this 
operation  is  difficult,  from  the  oblique  direction  of  the  buccal  extremity 
of  this  passage,  and  from  the  curve,  it  forms  before  the  masseter 
muscle ;  to  avoid  these  obstacles,  Lewis  states,  that  we  must  introduce 
the  fingers  into  the  mouth,  raise  the  cheek  and  draw  it  forward. 

O  • 

Boyer  remarks,  that  in  children,  the  superficial  button  of  fat  often 
projects  between  the  lips  of  the  wounds.  Some  bruising  bodies  may 
produce  fractures  of  the  skeleton  of  .this  region,  and  may  enter  the 
maxillary  sinus,  and  by  continuing  there  may  cause  bad  symptoms. 
Fractures  of  the  upper  jaw  are  not  in  themselves  very  dangerous,  but 
as  they  are  generally  attended  with  a  more  or  less  serious  concussion 
of  the  cerebrum,  they  are  more  important  than  fractures  of  the  lower 
jaw :  when  these  are  oblique,  the  fracture  is  generally  directed  down- 
ward and  backward,  which  facilitates  the  depression  of  the  anterior 
fragment  by  the  muscles  of  the  supra-hyoid  region.  The  fracture 
may  occur  in  the  centre  of  the  body  of  the  bone,  near  the  angular 
insertion  of  the  masseter  and  pterygoideus  internus  muscles,  or  finally, 
at  the  neckof  the  condyle.  In  the  first  case,  while  the  mental  fragment 
is  displaced,  as  we  have  mentioned  above,  the  posterior  rests  against 
the  upper  jaw,  being  kept  there  by  the  masseter  and  pterygoideus 
internus  muscles ;  in  the  second  case,  these  two  muscles  prevent  all 
displacements,  because  being  attached  to  the  two  fragments,  they 
act  upon  them  equally,  and  in  the  same  direction ;  finally,  in  the  third, 

*  Deroi  and  Duphoenix  made  but  one  internal  opening ;  they  were  obliged  to  retain  a 
thread  in  the  external  part  of  the  wound  to  keep  in  place  the  dilating  body  on  the  inside. 
Deguise  has  improved  this  method,  by  proposing  to  make  two  internal  openings,  through 
which  the  two  extremities  of  the  dilating  body  can  be  brought  into  the  mouth,  and  be 
attached  without  an  external  thread. 


86  TOPOGRAPHICAL    ANATOMY. 

the  upper  fragment  alone  is  displaced  and  goes  forward,  obeying  the 
action  of  the  pterygoideus  extemus  muscle.  The  laceration  of  the 
dental  nerve  in  fractures  of  the  jaw,  attended  with  great  displacement, 
has  sometimes  produced  tetanus,  or  a  paralysis  of  the  chin.  The 
nervous  and  vascular  communications  between  the  cheeks  and  gums, 
and  their  direct  relations,  establish  a  mutual  dependance  between 
these  two  regions  ;  in  fact,  if  the  malar  region  be  aifected  by  cold,  it 
swells  first,  and  then  the  teeth  become  painful ;  if  the  latter  be  affected 
primitively,  the  malar  region  often  becomes  the  seat  of  a  phlegmon, 
which  is  termed  a  fluxion,  and  which  may  present  all  the  terminations 
of  this  disease ;  when  the  pains  in  the  teeth  and  consecutive  swelling 
are  caused  by  caries,  this  often  terminates  in  an  abscess,  and  also  in  a 
fistula,  which  differ  from  the  salivary  fistulae  mentioned  before.  Severe 
pains  sometimes  extend  to  the  cheek  in  different  directions  :  sometimes 
they  emanate  from  a  point  near  the  lower  eyelid  and  descend  toward 
the  nose  and  the  lips ;  this  is  infraorbitar  neuralgia ;  sometimes 
they  commence  at  the  chin  and  ascend  toward  the  cheek,  this  is 
mental  neuralgia ;  in  other  cases,  the  pains  extend  from  the  parotid 
to  the  malar  region,  following  transverse  and  slightly  oblique  direc- 
tions ;  this  is  facial  neuralgia.  These  affections,  which  are  termed  tic 
douloureux  of  the  face,  are  sub-acute  or  chronic :  they  may  be  more  or 
less  intermittent :  the  affection  of  the  facial  nerve  is  more  common  than 
of  the  others,  and  habitually  produces,  during  its  access,  a  redness  of  the 
corresponding  cheek,  which  contrasts  with  the  paleness  of  the  opposite 
side  ;  this  phenomenon  is  connected  with  our  remarks  on  the  influ- 
ence of  the  diseased  nerve  on  the  color  of  the  cheek.  The  division 
and  even  the  removal  of  a  portion  of  the  affected  nerves  have  been 
attempted  in  several  cases,  by  many  distinguished  surgeons,  and  par- 
ticularly by  Roux,  but  always  with  transient  success ;  this  professor 
has  divided  successively,  in  the  same  individual,  the  infra-orbitar,  the 
mental  and  facial  nerves,  thus  pursuing  constantly  a  neuralgia 
which  fled  before  his  knife,  and  which  was  finally  seated  in  the 
ramifications  of  the  buccal  branch  of  the  inferior  maxillary 
nerve  ;*  in  consequence  of  these  neuralgias,  the  muscles  are 
sometimes  paralyzed.  I  know  a  lady  in  whom  the  facial  nerve  is 

*  When  the  facial  nerve  is  affected  with  neuralgia,  remedies  must  be  applied  to  it  in  the 
parotid,  and  not  in  the  malar  region,  which  course  is  prescribed  by  anatomical  reasons,  to  be 
stated  hereafter.  The  incision  necessary  in  dividing  the  infra-orbitar  nerve,  will  embrace 
necessarily;  the  skin,  a  cellular  layer,  the  orbicularis  palpebrarum  muscle,  and  the  levator  of 
the  upper  lip.  The  incision  for  the  submental  nerve  may  be  made  on  the  inside,  and  then 
would  interest  only- the  mucous  membrane ;  if  made,  on  the  contrary,  on  the  outside,  we  must 
divide  the  skin,  the  depressor  anguli  oris,  and  the  quadratus  menti  muscles :  the  inferior 
labial  artery  also  might  be  affected,  as  is  proved  by  the  relations  mentioned. 


MALAR  REGION.  .         87 

alone  affected ;  the  malar  region  preserves  its  power  of  mastication, 
but  has  lost  its  expression ;  in  smiling,  particularly,  it  is  curious  to 
observe  the  singular  contrast  on  the  two  sides  of  the  face :  one 
presents  very  various  motions ;  the  other  is  perfectly  still.  These 
facts  support  the  celebrated  experiments  of  Charles  Bell. 

Among  diseases  of  this  region  we  shall  briefly  mention,  gangrene, 
which  so  often  affects  the  cheeks  of  infants,  and  proceeds  from  the 
mucous  to  the  cutaneous  face.  Tumors  of  different  kinds  may  appear 
in  the  malar  region ;  those  formed  by  the  erectile  tissue  are  very  com- 
mon, as  might  be  presumed  from  their  vascularity  of  the  part,  indepen- 
dent of  experience ;  their  extirpation  is  often  attended  with  but  little 
deformity,  even  when  a  great  portion  of  this  region  has  been  removed, 
because  the  rest  readily  yields :  in  every  case,  in  order  to  favor  this 
tendency,  and  to  facilitate  the  union  of  the  wound,  the  cheek  should 
be  separated  for  some  distance  from  the  jaws,  by  cutting  the  fold, 
formed  by  the  passage  of  the  mucous  membrane,  near  the  gums. 
Some  tumors  of  the  jaw  are  produced  by  exostoses,  which  arise  from 
its  skeleton,  and  others  simply  by  the  dilatation  of  the  maxillary  sinus. 
This  sinus  may  be  considerably  enlarged,  when  a  polypus,  pus,  or 
serum  forms  in  its  cavity ;  but  these  foreign  bodies  depress  the  ante- 
rior wall  particularly,  and  act  but  slightly  upon  the  others ;  sometimes 
also,  but  rarely,  the  olfactory  wall  of  the  sinus  is  destroyed,  and  its 
cavity  blends  with  that  of  the  nasal  fossae  ;  more  frequently,  its  ante- 
rior wall  becomes  considerably  thinner,  and  wastes ;  the  soft  parts  of 
the  cheek  then  envelope  the  tumor,  which  may  also  be  felt  in  the 
mouth  under  the  mucous  membrane  ;  sometimes  the  molar  teeth  are 
loosened,  or  the  floor  of  the  sinus  is  crowded  on  their  roots,  and  soon 
perforated  by  them:  even  the  pressure  of  a  fluid,  acting  directly  and  for 
a  long  time  on  their  point,  has  curved  it  and  riveted  it  internally :  in 
other  cases,  fistulous  openings  form  on  the  alveolar  edge,  and  serve  for 
the  discharge  of  the  morbid  fluid  accumulated  in  the  maxillary  sinus, 
thus  pointing  out  to  the  physician  the  course  to  be  pursued,  to  relieve 
the  patient  promptly ;  the  puncture  of  the  maxillary  sinus  is  the  opera- 
tion for  the  cure  of  these  diseases.  The  place  selected  for  this  opera- 
tion is  the  lowest  part  of  the  sinus,  which  corresponds  to  the  alveoli  of 
the  first  and  second  great  molar  teeth :  farther,  its  wall  in  this  part 
is  formed  by  a  very  thin  plate  of  bone.  In  order,  however,  to  save  the 
teeth,  if  any  exist,  Desault  advises  to  perform  it  on  the  anterior  wall  of 
the  canine  fossa,  after  separating  the  soft  parts  of  the  cheek ;  La- 
morier  also  mentions  the  molar  tuberosity  as  the  most  proper  point ; 
but  if  we  follow  the  advice  of  these  celebrated  surgeons,  anatomy  de- 
monstrates, that  the  consecutive  suppuration,  which  must  necessarily 
occur,  would  only  take  place  in  part,  and  the  disease  would  not  be 


88  TOPOGRAPHICAL  ANATOMY. 

cured.  Ribes  has  related  very  curious  instances  of  military  men,  who 
have  survived  the  loss  of  the  lower  part  of  the  cheeks,  and  of  nearly 
the  whole  lower  maxillary  bone  ;  a  frightful  mutilation,  which,  by  dis- 
playing the  immense  resources  of  nature,  has  pointed  out  the  course  to 
be  followed  in  deep  affections  of  the  malar  region,  attended  with  disease 
of  the  lower  maxillary  bone :  in  this  case  the  bone  must  be  partially  or 
even  entirely  removed^  as  has  already  been  stated. 

6.   TONS  ILL  AR       REGION. 

The  amygdala  or  tonsil  and  the  surrounding  parts  form  a  small  region, 
which  is  more  important  in  a  pathological  than  in  an  anatomical  point 
of  view  :  it  forms,  with  the  pharynx  above  and  the  base  of  the  tongue 
below,  the  isthmus  of  the  fauces,  the  bucco-pharyngeal  opening.  The 
tonsillar  region  is  smooth  and  mucous  on  the  inside ;  it  is  bounded 
anteriorly  and  posteriorly  by  two  folds,  the  pillars  of  the  velum  palati : 
it  is  depressed  in  the  space  between  them,  and  is  marked  by  several 
openings  which  lead  into  the  lacunae  of  the  amygdalae :  its  external 
face  bounds  the  carotid  space,,  and  at  the  interval  between  the  horn  of 
the  hyoid  bone  and  the  angle  of  the  jaw,  the  vessels  of  this  space  rest 
directly  against  it. 

/Structure.  —  I.  Elements.  This  region  is  formed  principally  by  the 
amygdalae.  Its  different  granulations  pour  the  products  of  their  secre- 
tion into  the  common  lacunas,  which  open  on  the  mucous  membrane : 
^hese  lacunas  may  be  considered  as  the  rudiments  of  excretory  pas- 
sages :*  two  muscles  belong  specially  to  this  region,  the  glosso-,  and  pha- 
ryngo-staphylini  muscles,  and  also  a  small  portion  of  the  constrictor 
pharyngis  superior  muscle  ;  its  arteries  are  large  and  numerous  ;  they 
come  from  the  inferior  palatine  and  pharyngeal,  and  from  the  lingual 
and  the  superior  palatine  arteries ;  the  veins  empty  into  the  pharyn- 
geal venous  plexus,  while  the  lymphatic  vessels  terminate  in  the  sub- 
maxillary  ganglions :  the  nerves  of  the  tonsils  come  from  the  glosso- 
pharyngeal  nerve,  and  from  the  upper  cervical  ganglion  of  the  great 
sympathetic  nerve  :  we  have  looked  in  vain  for  those  branches,  which 
some  authors  say  come  there  from  the  lingual  and  hypoglossal  nerves. 
All  these  nerves  form  a  small  plexus,  improperly  termed  the  circulus 
tonsillaris.  The  mucous  membrane  presents  nothing  remarkable. 

2.  Relations.  From  within  outward,  the  mucous  membrane  forms  the 
first  layer  :  it  is  supported  anteriorly  and  posteriorly  by  the  glosso-sta- 
phylini  and  pharyngo-staphylini  muscles :  between  them  it  belongs  to 
the  tonsil,  and  penetrates  into  its  lacunae ;  finally,  we  find  more  deeply 

X 

*Thc  amygdalce  and  some  other  organs,  form  the  transition  between  the  follicles  and 
the  glands. 


MALAR  REGION.  S9 

the  constrictor  pharyngis  superior  muscle,  and  we  arrive  at  the 
carotid  region  and  the  vessels  situated  in  it.  Uses. — A  mucous  sub- 
stance constantly  exudes  from  the  surface  of  the  tonsil,  and  lubricates 
the  inner  face  of  this  region,  and  thus  facilitates  the  passage  of  the 
food  to  the  narrow  opening  of  the  isthmus  of  the  fauces. 

Pathological  and  operative  deductions.  In  inflammations  of  the 
tonsils,  the  patient  always  presents  a  more  or  less  remarkable  tume- 
faction below  the  angle  of  the  jaw :  this  is  the  part  on  the  outside  to 
which  this  region  corresponds,  and  also  the  part  where  the  ganglions, 
to  which  the  lymphatic  vessels  proceed,  are  situated :  in  these  cases,  the 
ganglions  are  swelled  sympathetically :  a  swelling  is  also  seen  on  he  in- 
side, and  then  the  amygdalae  project  beyond  the  staphyline pillars;  some- 
times abscesses  even  form  in  them,  which  must  be  opened,  being  careful 
not  to  introduce  the  instrument  too  deeply,  lest  the  important  parts 
in  the  carotid  space  be  injured:  for  the  same  reason,  the  extirpation  of 
the  tonsils  has  been  condemned ;  these  glands,  when  tumefied,  should 
be  removed  only  as  far  as  the  pillars  which  circumscribe  them.  Beclard, 
in  his  course  of  lectures,  mentioned  a  case  where  the  internal  carotid 
artery  was  opened,  and  the  patient  died :  this  was  doubtless  done  by 
some  surgeon  ignorant  of  the  anatomical  relations  of  the  parts.  In 
certain  affections  of  the  throat  in  children,  the  buccal  surface  of  this  re- 
gion is  covered  with  a  membranous  concretion,  which  Bretonneau  states 
is  often  confounded  with  eschars :  the  vascularity  of  this  part  of  the  isth- 
mus of  the  fauces,  explains  the  intensity  of  its  inflammations,  and  their 
different  consequences.  Celsus  speaks  of  calculi  in  the  amygdalae ; 
they  are  not  unfrequent. 


PARAGRAPH      "THIRD. 

OF    THE    ORBITS. 


The  orbits  are  bony  cavities,  in  the  upper  sides  of  the  face,  which 
contribute  to  the  base  of  the  cranium :  they  are  designed  to  protect  the 
apparatus  of  vision,  and  form  a  region  which  not  only  presents  exact 
limits,  but  those  also  formed  by  nature  for  a  very  important  physiolog- 
ical purpose ;  the  anatomy  of  this  part  also,  considered  as  a  region, 
has  long  been  studied :  nevertheless,  we  shall  make  it  the  subject  of 
important  remarks. 

The  orbitar  group  is  composed  of  two  orders  of  organs  :  some  are 
placed  in  front  of  it  upon  its  base,  while  others  occupy  its  cavity: 
hence  two  regions,  an  external  and  an  internal  orbitar  region.  The 
former  is  composed  of  the  tutamina  oculi  of  Haller ;  the  latter  of  the 
globe  of  the  eye,  and  its  motory  organs.  Both  are  intimately  connected  • 


»2 


90  TOPOGRAPHICAL    ANATOMY. 

with  the  brain  by  their  vascular  system,  and  are  separated  by  the  olfac- 
tory region. 

Development.  This  part  of  the  face  is  one,  of  the  first  which  appears 
in  the  fetus  :  its  internal  portion  forms  first,  the  external  afterward.  . 

Pathological  and  operative  deductions.— The  regular  development 
of  the  orbitar  organs  is  subsequent  to  the  formation  of  the  median 
region  which  separates  them :  hence,  when  this  is  not  formed,  the  two 
orbits  are  blended  on  the  median  line :  this  deviation  of  formation 
doubtless  gave  rise  to  the  fable  of  the  cyclopians.  This  anomaly  pre- 
sents many  degrees  ;  the  lowest  is  marked  by  the  existence,  in  one  very 
broad  orbit,  of  all  the  parts  which  are  situated  in  the  normal  state  on 
the  right  and  left  sides.  In  other  'cases,  there  is  but  one  eye  and  one 
orbit ;  but  it  always  presents  marks  of  the  union  of  two  in  one.  Tenon 
and  T.  Bartolini  have  each  mentioned  a  case  of  the  union  of  the  orbits, 
and  the  absence  of  the  eyes. 

The  vascular  communication  of  the  orbitar  parts  of  the  face  with 
the  cerebrum,  accounts  for  the  redness  of.  the  eyes,  and  for  many  other 
symptoms  of  cerebral  diseases ;  it  also  explains  reciprocally,  affections 
of  the  cerebrum  or  of  its  functions,  in  diseases  of  the  eyes. 

PARAGRAPH       FIRST. 
EXTERNAL  ORBITAR  REGION. 

The  external  orbitar  region  is  separated  on  the  inside  from  the  nasal 
region,  by  the  naso-palpebral  groove,  and  is  bounded  in  the  rest  of  its 
circumference  by  the  base  of  the  orbit,  which  is  easily  felt  by  depressing 
the  soft  parts ;  it  is  formed  by  two  small  ^ndary  regions,  the  eye- 
brow and  the  eyelids^ 

1.  Eyebrow.  This  small  mated  region  is  covered  with  hairs,  rests 
on  the  orbitar  arch,  is  arched  and  convex  upward,  and  its  limits  are 
marked  by  the  termination  of  .the  hairs.  The  two  eyebrows  often  blend 
at  their  inner  extremity,  the  .head  ;  the  outer  extremity,  the  tail,  extends 
to  the  temple. 

Structure.  —  I.  Elements.  The  supraciliary  arch  of  the  frontal  bone 
forms  the  skeleton  of  this  region,  to  which,  consequently,  the  frontal 
sinuses  correspond,  cavities  lined  by  a  part  of  the  pituitary  membrane, 
which  receives  its  vessels  from  the  external  part  of  this  region.  The 
corrugator  supercilii  muscle  is  the  only  special  muscle  of  this  region, 
the  occipito-frontalis  and  orbicularis  muscles  are  partially  connected 
with  it,  one  to  elevate,  the  other  to  depress  it :  the  skin  is  covered  with 
hairs,  the  coloj  of  those  of  the  head,  which  are  inserted  perpendicu- 
larly on  the  inside,  and  obliquely  in  all  other  parts :  we  find  there  but 
little  fat  and  adipose  tissue.  The  nerves  are  principally  twigs  of  the 


EXTERNAL  ORBITAR  REGION.  91 

external  and  internal  frontal  nerves,  and  of  the  facial  nerve :  the  trunks 
of  the  first  two,  pass  through  the  eyebrow.  Most  of  the  arteries  are 
given  off  by  the  ophthalmic,  and  but  few  by  the  temporal  artery.  The 
veins  and  lymphatic  vessels  present  nothing  peculiar. 

2.  Relations.  The  skin,  the  first  layer  of  the  eyebrow,  adheres  more 
firmly  above  than  below,  particularly  on  the  outside,  because  the  fibres 
of  the  corrugator  supercilii  muscle. are  inserted  in  it  in  this.  part.  The 
subcutaneous  layer  is  dense  and  a  little  fatty  at  the  upper  part;  it  covers 
a  first  muscular  layer,  resulting  from  the  union  of  the  fron  tails  and  the 
orbicular  is  muscles,  a  layer  through  which  the  fibres  of  the  corrugator 
supercilii  pass  obliquely  outward,  and  go  to  the  skin.  Below,  we  see  this 
latter  muscle,  which  rests  on  the  nervous  and  vascular  trunks  of  the  re- 
gion which  are  placed  at  the  union  of  its  inner  with  its  two  outer  thirds ; 
the  external  frontal  nerve  is  situated  farther  outward  :  finally,  we  come 
to  the  orbitar  arch,  and  the  .frontal  sinuses. 

Development.  The  eyebrows  are  destitute  of  hairs,  until  the  sixth 
month  of  pregnancy ;  they  project  but  little  in  early  life,  on  account  of 
the  slight  development  of  the  frontal  sinuses ;  in  the  adult,  and  parti- 
cularly in  the  old  man,  they  rise  considerably  above  the  orbit  for  an 
opposite  reason. 

Pathological  and  operative  deductions.  ,,  Wounds  of  the  eyebrows 
may  be  serious,  as  has  always  been  admitted ;  sometimes  they  cause 
death,  sometimes  amaurosis:  fractures  of  the  base  of  the  skull  by  a 
counterblow,  with  which  .they  are  often  attended,  explain  the  first ;  the 
second  has  long  been  attributed  to  an  injury  of  the.  supra-orbitar  nerve: 
an  explanation  which  has  been  rejected,  but  which,  however,  is  more 
admissible,  as  Magendie  has  demonstrated  that  the  fifth  pair  of  nerves 
has  a  remarkable  effect  on  vision.  .  Some  fractures  of  the  supraciliary 
arch,  with  a  depression  of  the  anterior  wall  of  .the  frontal  sinuses,  have 
sometimes  been  mistaken  for  lesions  of  the  entire  skull,  with  a  depres- 
sion of  the  fragments  towards  the  cerebrum :  their  worst  consequences 
are  fistulas  of  the  sinuses  admitting  air.  Tumors  containing  hairs  are 
not  unfrequent  in  this  region;  these  are  follicles  morbidly  developed. 
We  may  be -called  upon  to  divide  the  supra-orbitar  nerve  in  this  region, 
in  case  of  frontal  neuralgia;  this  is  easily  found  where  it  emerges  from 
the  supra-orbitar  foramen,  by  making  below  the  eyebrow  a  curved  in- 
cision concave  downward ;  we  must  not  forget,  in  this  trivial  operation, 
the  variable  position  of  the  external  branch  of  this  nerve. 

2.  The  eyelids  are  two  moveable  folds,  situated  in  front  of  the  ocular 

region,  which  open  and  close  -to  admit  or  exclude  the  light.     They  are 

distinguished  into  upper  and  lower  ;  they  differ  very  slightly ;  hence  we 

shall  describe  them  generally,  and  point  out  their  differences  afterward. 

General  description. — The  eyelids  .in  man  are  placed  in  a  perpen- 


92  TOPOGRAPHICAL   ANATOMY. 

dicular  plane :  they  unite  on  the  inside  and  outside,  in  two  commis- 
sures ;  the  one  is  the  internal,  the  nasal,  the  great  angle  of  the  eye : 
the  other,  the  external,  the  temporal,  the  small  angle  of  the  eye.  They 
have  an  anterior  face,  which  is  cutaneous,  smooth,  and  convex,  and  pre- 
sents more  or  less  distinct  semicircular  folds  ;  a  posterior  face,  which  is 
mucous  and  concave,  loose  at  the  centre,  and  attached  at  the  edges : 
their  circumference  is  continuous  with  the  nose,  the  temple,  the  eye- 
brow and  the  cheek,  at  the  points  mentioned  when  treating  generally 
of  the  external  orbitar  region ;  their  loose  edge  is  flat,  according  to 
Magendie ;  it  is  curved  in  its  external  five  sixths,  and  is  horizontal  near 
the  great  angle.  In  the  first  point  are  curved  and  very  coarse  hairs, 
the  eyelashes,  and  also  the  orifices  of  the  meibomian  glands,  the  ciliary 
follicles :  in  the  second  it  is  smooth,  and  has  no  follicular  openings : 
near  the  place  where  the  direction  of  this  edge  changes,  it  rises  in  a  per- 
forated tubercle,  the  punctum  lachrymale,  which  is  directed  backward 
and  inward,  forming  the  upper  orifice  of  the  lachrymal  canal. 

Structure.  —  I.  Elements.  Not  to  mention  the  base  of  the  orbit,  which 
supports  on  the  inside  the  lachrymal  sac,  and  on  which  the  eyelids  rest, 
the  latter  owe  their  resistance  to  the  tarsal  cartilages,  and  to  the  fibrous 
palpebral  membrane,  the  broad  ligament  of  some  authors ;  of  which 
membrane  the  tendon  of  the  orbicularis  muscle  is  only  an  addition  ; 
the  orbicularis  muscle  is  the  only  one  common  to  the  two  eyelids,  and 
almost  the  only  one  in  this  region.  The  lachrymal  canal  passes  through 
each  eyelid,  commencing  at  the  punctum  lachrymale.  The  skin  of  this 
part  is  remarkably  fine,  as  is  also  the  case  with  the  mucous  membrane, 
which  does  not  line  the  whole  of  this  region,  but  leaves  it  and.goes 
upon  the  eye :  this  forms  the  ciliary  follicles,  which  are  situated  perpen- 
dicularly, and  open  at  the  place  mentioned.  But  little  cellular  tissue 
exists  in  the  eyelids,  and  it  is  loose ;  fat  is  situated  only  at  the  posterior 
part.  The  arteries  belonging  exclusively  to  this  region  are  the  palpe- 
bral branches  of  the  ophthalmic  artery,  which  anastomose  with  some 
branches  of  the  facial,  the  temporal,  the  infraorbital,  the  supraorbital, 
and  the  lachrymal  arteries.  The  veins  follow  the  course  of  the  arteries. 
The  lymphatic  vessels  are  very  numerous,  and  most  of  them  go  to  the 
parotid  ganglions :  a  few  follow  the  facial  artery,  and  go  to  the  sub- 
maxillary  ganglions.  The  nerves  are  twigs  of  the  facial  nerve,  and  of 
the  fifth  pair,  the  latter  come  specially  from  the  ophthalmic  nerve  of 
Willis,  and  from  the  superior  maxillary  nerve. 

2.  Relations.  The  eyelids  are  composed  of  distinct  layers,  the  first 
of  which  is  formed  by  the  skin :  the  second  by  a  lamellar  cellular 
tissue,  moistened  by  an  abundance  of  serum,  and  never  containing  fat : 
next  comes  the  orbicularis  muscle,  separated  by  the  palpebral  arteries  from 
the  broad  ligament  and  from  the  tarsal  cartilages ;  more  deeply,  a  cellulo- 


EXTERNAL  ORBITAR  REGION.  93 

fatty  layer  which  is  very  abundant  near  the  circumference,  and  is  con- 
tinuous with  that  of  the  internal  orbitar  region,  but  is  slight  near  the 
loose  edge  where  it  covers  the  conjunctiva ;  this  membrane  is  then 
attached  to  the  tarsal  cartilages,  on  which  it  constitutes  the  meibomian 
glands.  The  relations  of  the  external  angle  of  the  eyelids  present 
nothing  peculiar ;  this  is  not  the  case  with  those  of  the  great  angle  : 
the  skin  is  finer  there  than  in  any  other  part,  and  shows  the  subjacent 
network :  below  it  is  a  cellulo-vascular  layer,  then  the  tendon  of  the 
orbicularis  muscle,  and  the  fleshy  fibres  which  arise  from  it,  the  anasto- 
mosis of  the  facial  and  ophthalmic  arteries,  and  also  that  of  the  ophthal- 
mic and  angular  veins :  more  deeply,  we  see  the  fibro-mucous  mem- 
brane of  the  lachrymal  sac,  the  upper  part  of  the  nasal  canal,  rising 
a  little  above  the  tendon  of  the  orbicularis  muscle,  and  receiving  the 
lachrymal  canals  ;  the  latter  are  situated  at  first  under  the  mucous  mem- 
brane, afterwards  in  the  centre  of  the  cellular  tissue  which  surrounds 
the  lachrymal  sac  and  is  continuous  with  that  of  the  orbit. 

Development.  The  eyelids  are  not  visible  until  the  tenth  week,  either 
because  they  do  not  exist,  or  because  they  are  transparent,  as  many 
think:  their  base  is  formed  first,  and  they  increase  towards  their 
loose  edge :  at  the  twelfth  week,  according  to  Meckel,  their  opposite  edges 
touch,  and  unite  by  their  mucous  layer ;  at  the  same  time  they  increase 
in  thickness,  and  remain  united  till  birth ;  this  state  continues  even 
longer  in  some  animals.  In  early  life,  the  fibro-mucous,  and  osseo- 
mucous  parts  of  the  lachrymal  canal  have  an  inverse  extent,  on  account 
of  the  slow  formation  of  the  bone ;  the  latter  is  slightly  developed,  the 
first,  on  the  contrary,  predominates. 

Characteristic  differences  of  the  eyelids.  These  are  few,  and  affect 
the  external  form,  and  the  structure,  but  not  the  development.  The 
upper  eyelid  is  alone  connected  with  the  eyebrow  ;  its  loose  edge  forms 
a  plane,  which  is  oblique  downward  and  a  little  backward,  describing 
a  curve  concave  downward ;  that  of  the  lower  eyelid  has  an  opposite 
direction  ;  the  eyelashes  are  arched  upward  in  the  former,  and  down- 
ward in  the  latter.  The  superior  punctum  lachrymale  is  directed  down- 
ward, the  inferior  looks  upward.  The  superior  lachrymal  canal  is  at 
first  directed  upward,  but  curves  once  to  go  downward  and  inward  :  the 
inferior,  on  the  contrary,  changes  its  direction  twice  ;  at  first  it  descends 
perpendicularly,  and  then  is  directed  inward  and  upward,  and  again 
descends,  after  being  united  to  the  superior. 

The  upper  eyelid  alone  possesses  a  levator  muscle,  which  we  shall 
study  in  the  internal  orbitar  region  ;  this  part  is  situated  directly  be- 
hind the  broad  ligament,  between  it  and  the  mucous  membrane ;  we 
add,  that  this  latter  ligament  is  stronger  superiorly,  that,  on  the  contrary, 
the  orbicularis  muscle  is  more  developed  inferiorly. 


94  TOPOGRAPHICAL  ANATOMY. 

Pathological  and  operative  deductions.  The  eyelids  may  be  de- 
ficient, or  they  may  continue  united  after  birth,  and  then  a  slight 
operation  is  necessary.  Wounds  of  this  region  are  often  extremely 
serious,  not  on  account  of  the  injury  of  the  layers  which  belong  to 
them,  but  in  those  of  the  upper  eyelid,  from  the  fracture  of  the  base  of 
the  skull,  either  directly,  when  the  wounding  instrument  has  pene- 
trated deeply,  or  by  a 'counterblow,  if  the  orbitar  edge  has  been  struck 
with  violence.  The  wounds  made  voluntarily  in  this  region  in  surgical 
operations  must  be  curved  as  much  as  possible  in  the  direction  of  the 
folds  of  the  eyelids,  between  which,  the  cicatrix  is  afterwards  concealed. 
The  loose  edge  of  the  eyelids  may  be  turned  inward  or  outward,  en- 
tropion,  ectropion,  when  the  skin  and  the  conjunctiva  are  unequal  in 
length.  In  the  former  case,  the  mucous  membrane  is  shorter  than  the 
skin,  either  because  the  former  is  contracted  or  because  the  skin  is  re- 
laxed :  in  the  second  case,  either  the  skin  is  shorter,  being  contracted  by 
a  burn,  or  by  a  wound  with  loss  of  substance,  or  the  mucous  membrane 
is  enlarged  by  an  inflammation.  The  whole  art  of  curing  these  defects 
in  the  direction  of  the  eyelids,  consists  in  restoring  the  equilibrium, 
by  removing  a  part  of  the  integuments  which  preponderate.  Inflam- 
mation may  affect  the  different  layers  of  this  region  and  constitute 
erysipelas,  palpebral  ophthalmia,  or  finally,  a  phlegmon  :  this  latter,  at 
the  large  angle  is  termed  anchylops.  The  laxity  of  the  subcutaneous 
tissue  explains  the  frequency  of  its  puffiness,  even  in  females  who  are 
menstruating.  Cancer  of  the  eye  sometimes  in  its  progress  attacks  the 
eyelids  :  cysts  are  often  developed,  sometimes  they  are  superficial  and 
sometimes  deep :  some  of  them  should  be  treated  externally,  others 
internally ;  these  tumors  are  often  bounded  by  a  reddish  cellular  mem- 
brane which  is  fungous  •  internally ;  they  then  contain  a  purulent 
matter.  The  prolapsus  of  the  upper  eyelid  is  always  complicated 
with  the  traction  of  the  eye  externally,  which  depends  on  an  anato- 
mical arrangement  to  be  mentioned  when  speaking  of  the  internal 
orbitar  region.  An  inflammatory  tumor  sometimes  appears  between 
the  eyelashes ;  it  is  situated  in  one  of  the  ciliary  follicles  ;  the  direction 
of  the  lashes  is  sometimes  bad  from  their  abnormal  insertion,  trichiasis  ; 
if  they  are  turned  inward,  the  only  way  of  remedying  this,  is  to  pull 
them  out  and  afterwards  destroy  their  bulb  with  the  actual  cautery. 
Jaeger,  in  this  case;  has  proposed  to  cut  off  the  loose  edge  of  the  eyelid, 
and  Beclard  has  incised  it  from  its  '  loose  edge  to  its  base  ;  but  these 
operations  are  not  admissible.  Finally,  the  eyelids  may  sometimes 
adhere  posteriorly  to  the  globe  of  the  eye,  and  a  slight  operation  is  re- 
quired to  separate  them.  The  puncfa  lachrimalia  may  be  obstructed  or 
obliterated  ;  in  the  latter  case,  A.  Munro  proposes  to  restore  them,  and 
A.  Petit  advises  to  make  an  artificial  passage  for  the  tears  behind  the 


INTERNAL  ORBIT AR  OR  OCULAR  REGION.  95 

eyelids.  For  the  first,  we  try  to  introduce  an  instrument,  and  these 
ducts  are  injected.  By  raising  the  upper  eyelid,  we  remove  the  only 
curve  of  the  superior  lachrymal  passage  ;  the  inferior  passage  cannot 
be  straightened,  because  it  has  two  curves ;  these  are  the  only  reasons 
why,  in  operating  for  fistula .Lachrymalis,  according  to  the  mode  .of 
Anel  and  Mejean,  we  use  the  superior  passage  for  introducing  an  in- 
strument into  the  lachrymal  ducts.  The  want  of  a  point  of  support 
on  the  cheek,  a  reason  which  is  not  founded  on  anatomy,  causes  the 
lower  passage  to  be  selected  for  injections.  Morgagni  and  J.  L.  Petit 
assert  that  the  lachrymal  passages  may  give  rise,  by  their  successive  di- 
latation and  ulceration,  to  a  lachrymal  tumor  and  fistula  >  but  the  lach- 
rymal sac  is  connected  most  directly  with  these  two  symptoms  of  the 
same  disease,  the  obstruction  of  the  nasal  canal :  sometimes  it  is  impos- 
sible to,re-establish  its  permeability,  sometimes,  and  more  frequently,  cir- 
cumstances favor  this.  In  the  former  case,  to  obtain  a  cure,  we  must 
make  an  artificial  passage  by  piercing  the  unguiform  bone :  in  the  second 
case,  the  passage  must  be  cleared,  by  the  methods  of  Anel,  Mejean, 
Laforest,  and  particularly,  by  a  modification  of  that  of  Petit.  In  the 
early  stages,  the  lachrymal  tumor  seems  strangulated  in  the  centre, 
which  depends  on  its  relation  anteriorly  with  the  tendon  of  the  orbi- 
cularis  palpebrarum,  which  resists  the  distention :  lachrymal  fistulae 
appear  below  this  tendon,  because  this  sloping  part  of  the  lachrymal 
sac  is  that  which  is  dilated  and  afterward  ulcerated.  The  relation  of 
the  tendon  of  the  orbicularis  muscle  is  also  used  by  surgeons  in  ope- 
rating for.  fistula  lachrymalis  ;  it  serves  as  a  guide  in  dividing  the  sac, 
whether  according  to  Munro's  operation  it  is  divided,  or  is  avoided 
by  cutting  below  it,  as  is  more  generally  done. 

6. INTERNAL   ORBITAR   OR   OCULAR   REGION* 

The  limits  of  this  region  are  fixed  by  its  skeleton,  which  belongs 
also  at  the  upper  part  to  the  region  of  the  base  of  the  skull,  below  and 
inward  to  the  olfactory  cavity  and  to  the  maxillary  sinus,  on  the  out- 
side, to  the  temple,  and  also  to  the  base  of  the  skull. 

Its  dimensions  and  its  direction  depend  on  those  of  the  orbitar  cavity ; 
the  first  vary  a  little  ;  but  this  is  not  true  of  the  second,  the  axis  of 
which  looks  forward  and  a  little  outward. 

The  only  anterior  face '-of  this  region  is  loose  and  must  be  examined 
first ;  it  is  alternately  concealed  or  exposed  by  opening  or  shutting  the 
eyelids  ;  in  the  centre,  which  is  formed  by  the  globe  of  the  eye,  we 
distinguish  ;  the  anterior  part  of  the  sclerotica,  (the  whjte  of  the  eye,) 
its  union  with  the  transparent  cornea,  and  finally,  the  cornea,  which  is 
situated  directly  in  the  centre  ;  from  the  transparency  of  the  cornea 


96  TOPOGRAPHICAL    ANATOMY. 

we  can  distinguish  more  deeply,  the  iris  and  the  opening  of  the  pupil 
which  appears  black,  because  the  dark  base  of  the  eye  is  seen,  in  front 
of  which  only  transparent  media  are  situated  ;  on  the  outside  of  the  eye, 
the  anterior  face  of  the  orbitar  region,  in  its  unattached  portion,  presents 
the  sinus  formed  by  the  reflection  of  the  conjunctiva,  in  which  some 
physiologists  assert  that  the  tears  flow  during  sleep ;  on  the  inside, 
we  see  a  prominence,  which  is  formed  by  a  mass  of  follicles  secreting 
a  gluey  matter ;  this  is  the  caruncula  lachrymalis,  on  which  the  con- 
junctiva forms  a  fold  termed  the  tnembrana  nictitans^  the  third  eyelid 
in  certain  nocturnal  animals. 

Structure.  —  1.  Elements.  The  skeleton  of  this  region  forms  its  boun- 
dary as  has  already  been  remarked,  and  is  composed  of  the  frontal  and 
sphenoid  bone  above ;  the  superior  maxillary,  the  palatine,  and  the 
malar  bones  below ;  the  ethmoid,  the  unguiform,  and  also  the  sphenoid 
bone  on  the  inside ;  finally,  of  a  portion  of  the  malar  bone  and  of  the 
temporal  wing  of  the  sphenoid  bone,  on  the  outside ;  these  bones, 
which  form  the  parietes  of  the  orbit,  are  united  by  sutures ;  of  these 
walls  the  external  alone  is  oblique  inward  and  backward,  the  others 
are  horizontal  or  directly  antero-posterior ;  we  have  already  men- 
tioned the  union  they  establish  with  other  regions ;  they  are  very  thin 
and  their  resistance  is  slight ;  in  this  latter  respect,  the  internal  is  dis- 
tinguished from  all  others ;  next  comes  the  superior,  then  the  inferior 
and  the  external ;  their  periosteum  is  continuous  with  the  dura-mater, 
the  external  wall  unites  with  the  upper  and  inferior,  and  forms  two 
fissures,  one  superior,  the  other  inferior,  both  of  them  external ;  we 
shall  call  the  first  the  cranial,  the  other  the  zygomatic,  according  to 
their  relations.  The  globe  of  the  eye  occupies  the  centre  of  the  cavity, 
and  is  formed  by  numerous  elements,  the  description  of  which  does 
not  belong  to  our  work,  but  all  of  which  will  be  mentioned  when 
speaking  of  the  relations  ;  we  will  only  say  that  in  some  of  them  the 
rays  of  light  are  refracted^  while  in  others  they  are  absorbed ;  one 
alone  forms  a  sensitive  layer  for  receiving  impressions,  and  others  are 
protecting  parts ;  finally,  we  find  in  it  vessels  of  all  kinds  and  nerves, 
but  no  cellular  tissue  nor  fat.  The  orbit  contains  seven  muscles ;  six 
of  them  are  motors  of  the  globe  of  the  eye^  one  alone  belongs  to  the 
upper  lid  :*  among  the  first,  four  of  them  are  straight  and  two  of  them 
are  oblique.  A  considerable  mass  of  cellular  and  adipose  tissue  forms 
an  elastic  cushion  behind  the  eye,  on  which  the  latter  moves ;  this 
cellulo-fatty  mass  communicates  through  the  upper  and  lower  orbitar 
fissures  with  the  cellular  tissue  of  the  skull  and  that  of  the  zygomatic 

*  Authors  assert,  but  wrongly,  that  the  levator  palpebrse  superioris  muscle  terminates 
anteriorly  in  a  thin  aponeurosis ;  we,  however,  have  proved  the  contrary.  Its  fibres  only 
separate,  and  become  paler,  which  circumstance  has  doubtless  contributed  to  the  error 
mentioned. 


INTERNAL  ORBIT AR  OR  OCULAR  REGION.  97 

region.  The  orbitar  arteries  come  from  the  ophthalmic,  which  is  given 
off  by  the  carotid  cerebral  artery ;  which  arrangement  from  the 
circulation  of  this  region  must  be  considered  as  an  appendage  of 
the  circulation  of  the  brain  ;  the  trunk  of  the  ophthalmic  artery,  as  has 
been  seen,  anastomoses  with  those  of  the  face  and  temple.  The  veins 
go  to  the  skull  in  a  common  trunk  and  open  into  the  cavernous  sinus : 
the  ophthalmic  vein  also  may  be  compared  in  respect  to  its  arrangement 
with  the  great  emissary  veins.  The  lymphatic  vessels  are  but  little 
understood ;  some  appear  to  go  toward  the  base  of  the  cavity,  others 
descend  through  the  lower  orbitar  fissure.  The 'second,  third,  fourth, 
and  sixth  pairs  of  nerves  are  appropriated  entirely  to  this  region,  where 
we  find  also  the  upper  branch  of  the  fifth  pair,  which  only  passes 
through  it  and  gives  off  no  special  ramifications  ;  we  also  find  there 
the  ophthalmic  ganglion,  the  anterior  angles  of  which  give  off  the  ciliary 
rterves,  while  the  posterior  angles  communicate  each  by  a  filament 
with  the  common  motor  nerve  and  with,  the  nasal  branch  of  the 
ophthalmic  nerve  of  Willis. 
2.  Relations.  The  relations  of  this  region  are  difficult,  and  hence 

O  ' 

they  must  be  laid  down  very  strictly.  The  globe  of  the  eye  and  the 
optic  nerve  form  an  axis,  around  which  the  other  organs  are  placed  : 
but  we  must  first  attend  to  the  special  arrangement  of  the  eye  itself. 

.  1.  If  we  pierce  it  with  a  needle  in  the  direction  of  its  axis,  we 
perforate  successively ;  the  conjunctiva,  which  passes  on  the  cornea  ; 
the  different  layers  of  the  cornea,  which  are  separated  by  a  transpa- 
rent fluid  ;  the  anterior  fold  of  the  membrane  of  the  aqueous  humor  ; 
we  then  come  into  the  anterior  chamber  of  the  eye,  a  space  formed  by 
a  concave  anterior  wall  and  a  posterior  wall  which  is  perfectly  plane  ; 
after  passing  through  this  chamber,  which  is  filled  with  the  aqueous 
humor,  the  needle  penetrates  into  the  posterior  chamber  freely  in  the 
centre,  through  the  opening  of  the  pupil,  which  is  surrounded  by  a 
very  remarkably  small  arterial  circle  ;  on  the  outside  of  the  pupil,  it 
wounds  the  iris  and  the  three  layers  which  compose  it,  the  first  be- 
longing to  the  membrane  of  the  aqueous  humor,  the  second  formed 
by  .the  special  tissue  .of  the  iris,  the  latter,  the  uveal  membrane,  the 
internal  layer  of  the  choroid  membrane.  This  posterior,  chamber  is 
smaller  than  the  anterior,  and  is  also  filled  with  the  aqueous  humor 
in  the  adult :  it  is  closed  anteriorly  by  a  plane  wall,  and  posteriorly  by 
a  convex  wall,  while  the  circumference  is  formed  by  the  ciliary  pro- 
cesses, folds  of  the  internal  coat  of  the  choroid  membrane,  After 
passing  through  this  space,  the  instrument  arrives  more  deeply  at  the 
hyaloid  and  the  crystaline  capsules  ;*  the  humor  Morgagni,  which 

*  The  crystaline  lens  has,  in  fact,  two  envelopes  or  capsules  ;  its  proper  capsule,  and  one 
from  tiie  vitreous  bodv. 


98  TOPOGRAPHICAL    ANATOMY. 

separates  this  latter  from  the  tissue  of  the  crystaline  lens,  escapes,  the 
lens  is  perforated,  and  the  needle  comes  into  the  vitreous  body,  where 
it  may  wound  the  central  artery  which  passes  through  the  hyaloid 
canal  discovered  by  Jules  Cloquet:  finally,  beyond  this  space  in  which 
the  vitreous  body  is  situated,  we  fall  successively  on  the  retina,  the 
choroid  membrane,  and  the  sclerotica ;  it  must  be  directed  a  little 
inward,  to  arrive  at  the  insertion  of  the  optic  nerve. 

2.  If  we  pierce  the  eye  from  without  inward,  at  the  union  of  the 
cornea  with  the  sclerotica,  the  needle  would  wound  successively  the 
conjunctiva,  the  union  of  the  two.  preceding  membranes,  the  ciliary 
circle,  which  adheres  to  them  intimately  on  the  inside,  the  great  cir- 
cumference of  the  iris,  and  its  great  arterial  circle :  if  we  then  incline 
its  point  a  little  backward,  it  would  wound  the  ciliary  processes,  and 
would  penetrate  into  the  posterior  chamber ;  if  we  then  incline  it  for- 
ward, it  would  come,  on  the  contrary,  into  the  anterior  chamber,  after 
passing  through  the  membrane  of  the  aqueous  humor.  Finally,  two 
lines  or  more  from  the  union  of  the  cornea  with  the  sclerotica,  the 
needle  will  pass  through,  in  order  to  arrive  at  the  crystaline  lens 
anteriorly,  and  the  hyaloid  capsule  posteriorly,  the  sclerotica,  the  cho- 
roid membrane,  and  the  retina;  between  the  first  two  some  vessels 
and  nerves  of  the  iris  will  sometimes  be  wounded,  and  sometimes  the 
instrument  will  glide  between  these  filaments,  which  proceed  from 
behind  forward. 

On  the  'outside  of  the  eye  and  the  optic  nerve,  central  parts  of  the 
internal  orbitar  region;  the  relations  must  be  examined  superiorly, 
inferiorly,  externally,  internally,  and  anteriorly.  1.  Superiorly.— 
The  bone  with  its  periosteum  being  removed,  we  find  the  supra-orbi- 
tar  vessels  and  nerves  extending  along  the  orbit,  and  posteriorly,  only 
the  pathetic  nerve  directed  inward ;  more  deeply,  the  levator  palpebrae 
superioris  muscle  ;  next,  the  rectus  oculi  superior  muscle ;  below,  the 
vessels  of  the  superior  muscle  and  the  ascending  branch  of  the  com- 
mon motor  nerve ;  finally,  in  the  centre  of  the  fat,  directly  on  the 
optic  nerve,  the  nasal  nerve  and  the  ophthalmic  artery,  which  go  from 
without  inward,  then  the  ciliary  vessels  and  nerves,  which  are  parallel 
with  the  optic  nerve.  2.  Inferiorly. — The  bone  being  removed  and 
also  the  infra-orbitar  vessels  and  nerves  which  are  there  situated 
first  in  a  groove  and  then  in  a  canal,  we  discover  successively ;  the 
rectus  inferior  and  the  obliquus  minor  muscles,  the  lower  branch 
of  the  common  motor  nerve,  and  the  filament  which  it  sends  to  the 
ophthalmic  ganglion,  and  finally,  the  inferior  muscular  vessels  which 
are  situated  in  the  midst  of  the  fat.  3.  Internally.— On  removing  the 
olfactory  wall,  and  looking  toward  the  optic  nerve  and  the  eye,  we 
perceive  first  a  plane  formed  by  the  obliquus  superior  muscle  above, 


INTERNAL    ORBITAR    OR    OCULAR    REGION.  99 

and  the  rectus  interims  below,  and  between  them  by  the  nasal  nerve 
and  the  ethmoidal  arteries ;  more  deeply,  in  the  centre  of  the  fat  come, 
first,  posteriorly,  the  end  of  the  pathetic  nerve  and  also  the  nasal 
nerve,  which  is  soon  situated  in  the  preceding  plane ;  second,  anterior- 
ly, the  ophthalmic  artery  and  vein.  4.  Externally. — Below  the  bones, 
through  which  pass  some  nervous  and  vascular  filaments  which  serve 
to  anastomose  with  the  temple,  we  find  the  lachrymal  nerves  and  ves- 
sels, and  the  lachrymal  gland  superiorly ;  below,  the  rectus  externus 
muscle,  which  bifurcates  posteriorly,  and  thus  gives  passage  to  the 
common  motor,  the  external  motor,  and  the  nasal  nerves ;  finally, 
between  this  muscle  and  the  eye,  some  adipose  tissue,  in  which  the 
nasal  nerve,  the  ophthalmic  artery  and  ganglion  are  situated,  posteri- 
orly. 5.  Anteriorly. — After  removing  the  eyelids,  the  anterior  plane 
is  perfectly  exposed ;  it  is  formed  around  the  eye  by  much  cellular 
and  adipose  tissue,  in  which  we  distinguish,  first,  above,  emerging 
from  this  region,  the  supra-orbitar  vessels  and  nerves  which  curve 
upward,  the  levator  palpebra3  superioris  muscle,  the  anterior  extremity 
of  the  lachrymal  gland,  the  reflected  tendon  of  the  obliquus  superior 
muscle,  and  the  extremity  of  the  ophthalmic  artery;  second,  below,  the 
obliquus  inferior  muscle,  which  turns  the  eye  upward  and  outward. 

Development.  The  internal  orbitar  region  is  developed  before  the 
external ;  it  is  very  prominent  in  the  early  periods  of  life,  and  is  dis- 
tinguished by  a  black  point,  the  rudiment  of  the  globe  of  the  eye  ;  the 
osseous  frame  forms  at  a  later  period.  The  description  of  the  differ- 
ent forms  assumed  successively  by  the  eye,  belongs  to  descriptive 
anatomy ;  but  their  importance,  and  also  their  omission  in  many  ele- 
mentary treatises,  determines  us  to  mention  them  here.  The  eye  is 
formed  at  first  of  parts  which  are  perfectly  transparent,  not  excepting 
the  sclerotica ;  it  is  spherical,  but  afterwards  becomes  flattened ;  the 
cornea  is  very  prominent,  and  the  whole  anterior  chamber  is  dilated 
by  the  continuance  of  the  aqueous  humor  in  this  point,  according  to 
J.  Cloquet ;  during  the  first  months  of  fetal  existence,  this  chamber 
does  not  communicate  with  the  posterior ;  the  continuity  is  established 
afterwards,  by  the  rupture  of  the  membrane  which  closes  the  pupil, 
which  membrane  Cloquet  has  discovered  to  be  formed  by  two  layers, 
one  of  which  belongs  to  the  membrane  of  the  aqueous  humor ;  the 
plexuses  of  the  arteries  of  the  iris  extend  between  these  two  layers 
of  the  pupillary  membrane,  which  arteries  anastomose  from  their 
sides,  and  not  from  their  convexity.  At  the  seventh  month,  the  pu- 
pillary membrane  breaks,  and  the  pupil  is  formed.  As,  according  to 
Cloquet,  this  rupture  is  caused  by  the  retraction  of  the  arterial  plex- 
uses, or  by  the  absorption  of  the  centre  of  the  membrane,  the  small 
and  arterial  circle  of  the  iris  is  then  formed  regularly.  The  posterior 


100  TOPOGRAPHICAL    ANATOMY. 

chamber,  the  parietes  of  which  were  previously  contiguous,  dilates  by 
the  presence  of  the  aqueous  humor.*  The  crystaline  lens  is  at  first 
very  soft;  and  formed' of  three  segments,  separated  by  three 'linear 
spaces,  which  contain  a  fluid  analogous  to  the  humor  of  Morgagni. 
The  centre  of  this  organ,  however,  is  formed  before  its  circumference. 
The  vitreous  body  is  very  much  developed  before  birth.. 

Varieties.  The  ophthalmic  artery  frequently  passes  below  the 
optic  nerve ;  sometimes  it  is  divided  into  two  branches,  which  em- 
brace the  nerve,  and  afterwards  reunite  ;  one  of  these  two  roots  often 
represents  the  common  origin  of  the  artery,  the  other  comes  from  the 
middle  meningeal  artery,  and  passes  through  the  sphenoid  fissure ;. 
sometimes  the  middle  meningeal  artery  gives  oif  only  the  lachrymal' 
artery.  Although  the  eye  is  very  prominent  in  the  normal  state,  it  is 
sometimes  situated  very  deeply,  which  may  depend  on  two  causes : 
first,  the  greater  or  less  depression  of  the  bony  arch  of  the  cavity ; 
second,  the  variable  development  of  the  cushion  of  fat  at  the  poste- 
rior part  of  the  eye.  .  In  albinoes,  the  bottom  of  the  eye  and  also  the 
pupil  appear  red,  which  depends  on  the  absence  of  the  black  pigment 
of  the  choroid  coat. 

Pathological  and  operative  deductions.  The  whole,  or  a  part  of  the 
pupillary  membrane,  may  continue  after  birth.  These  varieties  are  ex- 
plained by  anastomoses,  formed  abnormally  between  the  convexity  of 
opposite  or  simply  contiguous  arterial  plexuses  of  the  pupillary  mem- 
brane ;  in  the  former  case  the  'rupture  cannot  occur  ;  in  the  second 
case  it  occurs,  but  leaves  through  life  a  floating  fold  of  the  membrane, 
Beclard,  in  his  lectures,  mentioned  a  striking  instance  of  this  latter 
arrangement. 

Wounds  of  this  region,  if  they  affect  the  globe  of  the  eye,  may  destroy 
it  immediately  or  by  consecutive  inflammation;  they  may  also  be  fol- 
lowed with  specks,  or  opacity  of  the  transparent  media :  when  exte- 
rior to  the  globe  of  the  eye,  they  are  not  very  serious,  except  where  the 
piercing  instrument  penetrating  deeply,  they  are  complicated  with 
an  injury  of  the  orbitar  arch,  of  the  internal  and  external  bony  parietes, 
or  of  the  organs  situated  in  the  sphenoid  fissure  and  zygomatic  fossa. 
Farther,  in  extirpating  the  eye,  we  must  guard  against  plunging  the 
instrument  too  deeply,  in  order  to  avoid  these  complications  :  the  lachry- 
mal gland,  ought  also  to  be  removed  in  this  operation,  because  the  con- 
tinual secretion  of  the  tears  would  be  injurious.  Sometimes  we  may 
amputate  the  globe  of  the  eye  instead  of  extirpating  it ;  we  must  then 
be  careful  to  cut  it  beyond  the  iris,  lest  this  membrane  should  contract 

*  This  is  Jules  Cloquet's  opinion :  we  must,  however,  observe,  that  Edwards  thinks,  before 
•the  rupture  of  the  pupillary  membrane,  the  aqueous  humor,  on  the  contrary,  occupies  the 
.posterior  chamber,  6r,  according  to  him,  is  formed  by  the  ciliary  processes. 


INTERNAL  ORBITAR  OR  OCULAR  REGION.  101 

in  its  centre,  and  prevent  the  evacuation  of  the  vitreous  humor,  and 
consequently  the  formation  of  a  stump  for  the  insertion  of  an  artificial 
eye.  We  have  'observed  a  case  of  this  kind  at  the  Hospital  la  Gharite  ; 
Boyer  was  obliged  to  operate  a  second  time.     The  eye  may  be  carried 
forward,  and.  may  project  between  the  eyelids  ;  this  is  exophthalmia,  a 
symptom  of  many  deep  diseases  of  the.  orbit,  such  as  inflammation, 
osseous,  erectile  or  fungous  tumors  of  the  dura  mater.  Inflammation  of 
the  orbit  is  very  severe,  and  may  be  fatal ;  it  easily  extends  to  the  zygo- 
matic   region,  through  the  inferior  orbitar  fissure,  and  particularly 
through  the  superior  into  the  cranium,  around  the  cavernous  sinus,  or 
even  into  this,  when,  there  is  at  the  same  time,  as  we  have  seen  twice, 
an  inflammation  of  the  ophthalmic  vein.  Travershas  cured  an  erectile 
tumor,  which  had  caused  exophthalmia,  by  tying  the  primitive  carotid 
artery.    A  polypus,  developed  in  the  maxillary  sinus,  may  produce  ex- 
ophthalmia,  by  raising  the  superior  wall  of  this  sinus.    The  connexion 
of  the  vessels  of  this 'region,  with  those  of  the  brain,  explains  the  redness 
of  the  eye,  and  the  pains  of  the  orbit,  in  cerebral  affections.  In  ophthal- 
mia, the  conjunctiva  of  the  eye  is  most  commonly  diseased,  that  which 
passes  on  the  cornea  is  often  affected  at  the  same  time  ;  this  last  is  inject- 
ed and  slightly  swelled,  on  account  of  its  intimate  adhesion ;  the  sac 
which  rises  above  the  cornea,  in  chemosis,  forms  at  the  place  where  this 
union  suddenly  becomes  very  loose.    Sometimes  the  cornea  alone  is 
inflamed,  softens  and  ulcerates,  or  is  relaxed  and  dilates  in  the  form  of 
a  sac,  staphylona.     The  spots  which  appear  on  this  membrane,  are 
situated  sometimes  on  the  conjunctiva,  nebula, ;  sometimes  they  result 
from  the  opacity  of  the  interlaminar  fluid;  albugo  ;  or,  finally,  they  are 
cicatrices,  leucoma.     The  diseases  of  the  aqueous  humor,  of  the  iris,  of 
the  crystaline  lens,  and  of  the  vitreous  humor,  are  marked  by  modifica- 
tions in  the  properties  of  these  parts,  which  can  be  perceived  by  examin- 
ing the  eye.     Of  these  diseases,  cataract  is  the  most  frequent :  it  is 
caused  by  the  opacity  of  the  crystaline  membrane,  of  that  of  the  crys- 
taline lens,  of  the  humor  of  Morgagni,  or  simply  of  the  crystaline 
tissue,  in  the  points  where  the  three  segments  which  form  it  in  early 
life  unite :  these  cataracts  are  the  membranous,  the  crystaline,  the 
milky,  and  the  diffuse.     Old  men  are  subject  to  a  varicose  state  of  the 
choroid  veins,  in  consequence  of  which,  the  pigment  of  the  choroid 
membrane  disappears  in  the  points  corresponding  to  the  varices,  and 
the  vision  is  very  much  impaired.  In  extracting  a  cataract,  we  must  re- 
member that  the  cornea  is  very  thick,  and  hence  the  instrument  should 
act  upon  it  perpendicularly,  in  order  to  cut  it  evenly;  we  must  avoid 
the  small  circle  of  the  iris  with  the  instrument,  which  should  not  be 
introduced  very  far  forward,  lest  the  vitreous  body  be  opened,  and  its 
humor  be  partially  evacuated.    This  accident,  however,  is  not  always 


102  TOPOGRAPHICAL  ANATOMY. 

fatal.  In  depressing  the  cataract,  the  sclerotica  is  wounded,  two  lines 
from  its  union  with  the  cornea,  to  avoid  the  retina  posteriorly,  the 
ciliary  circle  and  the  iris  anteriorly ;  we  always  wound  the  conjunc- 
tiva and  the  sclerotica,  the  choroid  membrane,  the  ciliary  processes, 
the  vitreous  body,  and  the  crystaline  lens ;  the  needle  is  carried  below 
the  external  extremity  of  the  transverse  diameter  of  the  eye,  to  avoid 
the  long  ciliary  artery,  which  is  situated  in  this  part ;  finally,  the  con- 
vexity of  the  needle  is  turned  upward,  because,  in  this  position,  it  pre- 
sents its  greatest  diameter  longitudinally,  and  thus  the  ciliary  vessels 
and  nerves,  which  go  from  behind  forward,  are  less  liable  to  be  wound- 
ed. In  operating  for  artificial  pupil,  the  great  arterial  circle  of  the  iris 
may  be  wounded;  this  accident  is  peculiar  to  it.  After  operating 
deeply  upon  the  eye,  it  inflames ;  its  internal  parts  swell,  and  if  they 
are  not  freely  divided,  the  extreme  resistance  of  the  envelopes  may 
produce  strangulation ;  hence  severe  and  deep  seated  pains,  and  loss 
of  vision  ;  if  the  cornea,  on  the  contrary,  is  divided,  the  aqueous  humor 
escapes ;  hence  the  inflammation  is  arrested,  and  it  is  never  strangu- 
lated, and  the  internal  parts  may  swell  as  much  as  this  change  requires. 
From  these  facts  extraction  seems  to  us  preferable  to  depression,  in 
operating  for  cataract ;  the  most  celebrated  practitioners,  however,  are 
still  divided  in  their  opinions  on  this  subject. 

I 


PARAGRAPH      FOURTH. 

ZYGOMATIC    FOSSA. 


This  region  is  situated  deeply  below  the  temple,  between  the' cra- 
nium and  the  face  above  the  masseteric  portion  of  the  malar  region, 
on  the  inside  of  the  parotid  region,  and  on  the  outside  of  the  orbit  and 
the  nasal  fossae,  with  which  it  is  connected  by  the  nerves  and  vessels. 

It  is  difficult  to  determine  its  form ;  it  is  composed  of  two  portions, 
one  of  which  is  more  superficial,  the  zygomatic  fossa,  the  other  is 
more  deep,  the  spheno-maxillary  fossa :  both  are  united  by  the  pteryo- 
maxillary  fissure. 

Structure.  —  1.  Elements.  This  small  region  is  bounded  by  its 
skeleton ;  it  is  specially  formed  by  the  sphenoid  bone,  the  posterior 
part  of  the  superior  maxillary,  the  palatine,  the  condyle  of  the  lower 
maxillary,  a  part  of  the  temporal  and  the  ethmoid  bone  at  the  base. 
It  marks  the  two  portions  of  the  region  which  have  been  indicated ; 
they  communicate  with  the  orbit,  the  first  by  the  inferior  orbitar 

fissure  ;*  the  second,  near  the  point  where  this  last  fissure  unites  with 
x 

*  In  animals  this  fissure  enlarges,  the  orbit  and  this  region  are  less  distinct ;  in  fact,  in 
some  animals  theso  parts  are  entirely  blended. 


ZYGOMATIC  FOSSA.  103 

the  superior ;  in  the  summit  of  the  zygomatic  fossa  are  five  foramina ; 
only  one  of  these  deserves  our  attention,  the  spheno-palatine ;  it  is 
broader  than  the  others,  and  in  a  prepared  head,  it  establishes  a  com- 
munication between  the  spheno-maxillary  fossa  and  the  corresponding 
nasal  fossa.  The  condyle  of  the  jaw  arid  the  anterior  part  of  its  tem- 
poral articulation*  correspond  also  to  the  zygomatic  fossa.  This  arti- 
culation is  protected  on  the  inside  by  the  spine  of  the  sphenoid  bone 
and  the  internal  lateral  ligament  which  arises  from  it ;  on  the  outside, 
by  a  tubercle  of  the  zygomatic  process,  and  the  external  lateral 
ligament ;  posteriorly,  by  the  auricular  passage,  while  anteriorly,  it  is 
very  loose  ;  it  encloses  a  layer  of  fibrous  cartilage  which  is  often  per- 
forated in  the  centre,  and  finally,  it  is  lubricated  by  one  or  two 
synovial  membranes,  according  as  the  foramen  of  the  inter-articular 
layer  does  or  does  not  exist.  The  pterygoideus  internus  muscle  is 
situated  entirely  in  this  region  and  is  confined  to  its  lower  extremity. 
It  is  formed  by  two  fasciculi,  between  which  is  a  narrow  triangular 
space.  The  lower  extremity  of  the  temporalis  muscle  is  situated  in 
the  zygomatic  fossa.  The  internal  maxillary  artery  passes  through  it 
and  terminates  in  its  summit ;  it  gives  off  in  that  part  a  considerable 
number  of  branches,  among  which  are  thirteen  principal  twigs,  which 
have  received  special  names  ;  it  is  accompanied  by  a  vein  which  anas- 
tomoses superficially  with  the  facial  vein  as  has  been  mentioned.  The 
lymphatic  vessels  are  little  known,  they  go  to  the  parotid  and  the  deep 
cervical  ganglions  ;  the  nerves  are  numerous,  and  for  the  most  part 
only  pass  through  this  fossa ;  among  them  may  be  mentioned  the 
superior  maxillary  nerve  and  its  inferior  orbitar  and  dental  filaments, 
the  ganglion  of  Meckel,  the  inferior  maxillary  nerve,  which  is  divided 
into  two  branches,  a  superior  and  an  inferior ;  these  branches  are  sub- 
divided into  twigs,  which  are  ;  the  former,  the  two  deep  temporal 
twigs,  the  buccal  and  the  masseteric  ;  the  second,  the  lingual,  the 
dental,  and  the  superficial  temporal.  The  adipose  and  cellular  tissues 
are  very  abundant  at  the  upper  part ;  they  are  continuous  in  this  di- 
rection with  the  cellular  tissue,  which  fills  the  base  of  the  orbit. 

2.  Relations.  When  the  zygomatic  arch  and  the  lower  extremity  of 
the  temporalis  muscle  which  forms  the  first  layer  are  removed,  we  see 
the  external  face  of  the  pterygoideus  externus  muscle,  upon  which 
rest  the  deep  temporal  vessels,  and  the  masseteric  nerve;  the  two 
temporal  nerves  appear  in  this  layer,  only  when  they  emerge  between 
the  bone  and  the  pterygoideus  muscle ;  if  we  divide  this  muscle,  we 
penetrate  into  the  space  between  its  two  fasciculi,  where  the  buccal 

*  The  other  parts  of  the  temporo-maxillary  articulation  belong  to  the  parotid  and  malar 
regions  ;  it  is  situated  on  their  limits. 


104  TOPOGRAPHICAL  ANATOMY. 

vessels  and  nerve  and  a  portion  of  the  internal  maxillary  artery  are 
situated  ;  the  second  fasciculus  of  the  pterygoideus  muscle  is  found 
more  deeply,  in  front  of  which  the  third  portion  of  the  internal  max- 
illary artery  ascends  perpendicularly,  behind  the  malar  tuberosity ; 
while  below  pass  the  lingual  nerve  on  the  inside,  the  inferior  dental 
in  the  middle,  -and  the  superficial  temporal  posteriorly,  all  united  by 
anastomosing  filaments.  This  is  the  arrangement  of  the  parts  which 
occupy  the  first  portion  of  the  zygomatic  fossa :  in  the  second,  the 
spheno-maxillnry  fossa,  we  find  from  above  downward  ;  first,  the 
ophthalmic  vein  and  the  ophthalmic  nerve  of  Willis,  the  common  motor, 
the  pathetic  and  the  external  motor  nerves,  two  filaments  of  the  supe- 
rior cervical  ganglion,  parts  which  come  from  the  sphenoid  fissure; 
and  pass  through  the  spheno-maxillary  fossa,  to  go  into  the  orbit ; 
second,  the  superior  maxillary  nerve>  which  proceeds  from  behind 
forward ;  third,  the  ganglion  of  Meckel  which  is  continuous  with  the 
preceding  nerve,  is  situated  on  the  outside  of  the  sphenb-palatine  fora- 
men, and  sends  off  downward  the  palatine  filaments,  anteriorly  the 
posterior -dental,  posteriorly  the  vidian  twig,  a  ganglion  surrounded  by 
fat,  and  the  four  terminating  branches  of  the  internal  maxillary  artery, 
the  vidian,  the  pterygo-palatine,  the  superior  palatine,  and  the  spheno- 
palatine  arteries. 

Development.  The  zygomatic  fossa  is  very  narrow  in  the  young 
child  ;  but  then  its  communications  with  the  orbit  are  very  broad  ;  in 
the  adult  it  dilates,  and  at  the  same  time  the  orbito-zygomatic  fissures 
contract ;  in  the  old  man,  these  are  dilated  much  more,  on  account  of 
the  thinness  and  absorption  of  the  osseous  substance  which  forms  their 
circumference,  and  in  this  respect  only  the  infantile  state  reappears. 

Varieties.  The  internal  maxillary  artery,  instead  of  passing  be- 
tween the  two  portions  of  the  pterygoideus  externus  muscle,  often 
glides  on  the  outside  of  it. 

Pathological  and  operative  deductions.  Wounds  of  this  region 
are  very  severe :  first,  because  they  necessarily  suppose  that  the  piercing 
instrument,  before  arriving  there,  passes  through  the  cheek,  the  temple, 
the  parotid  region,  or  the  orbit ;  second,  because  it  is  almost  impossible 
for  the  branches  of  the  internal  maxillary  artery  or  its  trunk  to  escape. 
This  was  the  case  with  a  soldier,  in  whom  Marjolin,  in  1814,  tied  the 
primitive  carotid  artery,  which  aiforded  the  only  chance  of  arresting 
the  hemorrhage :  this  mode,  however,  is  uncertain,  on  account  of  the 
anastomosis  of  the  arteries,  as  this  skilful  professor  experienced.  This1 
region,  situated  between  the  cheek,  the  temple,  the  parotid  region,  the 
orbit,  the  nostrils,  and  the  skull,  has  often  served  to  establish  morbid 
communications  between  these  points,  by  the  continuity  of  the  vessels 
and  by  that  of  the  cellular  tissue.  We  have  seen  the  maxillary  sinus 


COCCYGCEAL  EXTREMITY  OF  THE  TRUNK.  105 

destroyed  at  its  posterior  part,  by  polypi,  which  appeared  in  the  zygo- 
matic  fossa,  which  then  advanced  farther,  and  even  to  the  temporal 
fossa.  We  have  already  cited  the  remarkable  instance  of  another 
polypus  which  had  followed  the  same  course,  coming  from  the  nasal 
fossa  through  the  enlarged  spheno-palatine  foramen  :  the  two  following 
cases,  which  occurred  at  the  Hospital  la  Charite,  point  out  still  better 
the  morbid  communications  between  the  regions  mentioned.  Two 
individuals,  one  after  the  neck  of  the  condyle  of  the  jaw  had  been 
broken,  the  other  after  a  panaris,  were  affected  with  a  swelling  in  the 
parotid  region :  soon  afterwards,  the  eye  projected,  the  brain  became 
affected,  and  they  died.  On  opening  their  bodies,  We  discovered  an 
inflammation  of  the  parotid,  temporal,,  and  internal  maxillary  veins, 
which  also  extended  to  the  ophthalmic  vein  and  the  cavernous  sinus. 
The  temporo-maxillary  articulation  can  only  be  dislocated  anteriorly, 
on  account  of  its  mechanism  and  its  looseness  in  this  direction  :  the 
condyle  then  frees  itself  from  the  transverse  root  of  the  zygomatic 
process,  and  goes  a  greater  or  less  distance  into  the  zygomatic  fossa, 
being  acted  upon,  by  the  unequal  force  of  the  external  pterygoideus 
muscle :  dislocation  may  be  produced  by  the  action  of  the  muscle  alone. 
Some  forces,  unconnected  with  the  zygomatic  fossa,  that  of  the  masseter 
and  of  the  pterygoideus  internus  muscles,  may  contribute  to  it,  when 
the  jaw  is  depressed  by  any  cause  :  the  tendency  of  these  last  muscles 
to  produce  dislocation,  when  the  jaw  is  elevated,  after  being  forcibly 
depressed,  is  admitted  by  no  one ;  and  anatomy  rejects  it,  because  the 
line  in  which  their  action  extends  is  anterior  to  the  maxillary  condyle. 


CHAPTER      II. 


OF      THE      COCCYGCEAL      EXTREMITY      OF     THE      TRUNK. 

The  coccygceal  extremity  of  the  trunk,  the  tail,  is  very  distinct  in 
most  animals  from  its  central  portion,  and  should  be  specially  con- 
sidered. In  man,  on  the  contrary,  it  is  very  small,  and  is  so  blended 
with  the  abdomen,  and  particularly  with  its  pelvic  portion,  that  it 
cannot  be  distinguished  at  first  view,  and  will  be  considered  when 
speaking  of  the  trunk. 
' 


106  TOPOGRAPHICAL  ANATOMY. 


SECTION   II. 


CENTRAL   PORTION   OP   THE   TRUNK. 

The  central  portion  of  the  trunk  contains  two  great  splanchnic 
cavities,  the  thorax  and  the  abdomen :  it  is  united  to  the  head  by  a 
circular  contraction,  the  neck. 


CHAPTER        I. 


OF      THE      NECK. 

The  neck  is  situated  between  the  chest  and  the  head,  and  is  an  ap- 
pendage of  the  latter. 

Its  form  is  irregularly  cylindrical :  it  is  convex  anteriorly,  and  evi- 
dently flattened  posteriorly.  Its  direction  is  a  curve  slightly  convex 
anteriorly.  Its  superior  and  inferior  boundaries  are  very  definite  an- 
teriorly, the  base  of  the  lower  jaw  on  one  side,  and  the  sternum  and  the 
clavicles  on  the  other  :  posteriorly,  however,  its  boundaries  are  slightly 
marked,  as  we  shall  show  when  speaking  of  the  region  of  the  nucha. 

The  neck,  when  considered  externally,  presents  two  faces,  on  which 
the  median  raphe  is  unequally  marked :  one  is  anterior,  where  its 
traces  are  extremely  slight ;  the  other  posterior,  where  they  are  very 
distinct. 

Some  organs  of  the  neck  have  a  special  cavity  ;  but  the  region  itself 
has  none. 

Structure.  The  base  of  the  neck  is  formed  by  the  cervical  portion 
of  the  spine  :  this  part  communicates  to  it  its  peculiar  direction,  and  is 
distinguished  by  its  transverse  flattening,  and  also  by  the  passages  of 
the  root  of  the  transverse  processes.  The  vertebral  canal  is  broader 
there  than  in  any  other  part:  it  has  the  form  of  a  triangle  with  rounded 


NECK.  107 

angles :  the  vertebral  layers  which  form  it  posteriorly,  are  separated 
by  great  spaces,  filled  by  the  yellow  ligaments  :  this  arrangement  ex- 
poses the  medulla  in  this  part  to  external  injury.  The  elements  of 
this  skeleton  of  the  neck  are  seven  vertebrae,  which  are  united  to  each 
other,  while  the  first  is  joined  to  the  head  in  a  mode  which  combines 
solidity  and  mobility:  to  avoid  repetition,  this  part  can  be  here 
described  only  in  a  general  manner,  as  it  belongs  to  almost  all  the 
secondary  groups  of  this  portion  of  the  trunk.  The  upper  part  of  the 
spinal  marrow,  particularly  the  brachial  enlargement,  belongs  to  the 
neck :  we  also  find  there  muscles,  which  partially  or  entirely  belong 
to  it,  some  of  which  may  be  referred,  in  respect  to  their  uses,  to  the  air- 
passages  and  the  digestive  apparatus ;  others  to  the  hyoid  bone,  the 
spine,  the  head,  the  thorax,  and  the  thoracic  members  :  we  also  observe 
the  different  vessels,  some  of  which  belong  to  the  neck,  others  to  the 
ar.m  and  the  head  ;  they  ascend  from  the  heart  towards  the  head,  or 
follow  an  opposite  direction.  Farther,  six  large  arterial  trunks  pass 
through  the  neck,  four  of  which  are  parallel  to  its  axis,  the  carotids 
and  the  vertebral  arteries,  and  are  enclosed  in  a  bony  canal ;  while 
two  appear  only  for  a  moment  at  its  base,  and  then  go  to  the  thoracic 
limbs,  the  subdavian  trunks.  The  principal  veins  of  the  neck  are 
four  large  veins,  which  are  termed  the  jugular  veins  :  two  of  them  are 
deep,  and  two  superficial.  We  also  find  a  great  many  lymphatic  gan- 
glions, the  common  rendezvous  of  all  vessels  of  this  order  which  arise 
from  the  neck  itself,  the  head,  the  thoracic  limbs,  and  some  parts  of  the 
chest :  ganglions  are  rare  upon  the  median  line,  but  are  situated  more 
particularly  on  the  side,  and  form  a  continuous  chain  from  the  ear  to 
the  thorax.  The  nerves  are  given  off  towards  the  thoracic  limbs  and 
the  thorax  :  sometimes,  but  rarely,  they  reascend  from  this  last  point, 
the  recurrent  nerves.  The  cervical  nerves,  which  emanate  from 
the  spine,  form  two  plexuses :  an  upper,  the  superficial,  the  branches 
of  which  are  distributed  almost  exclusively  to  the  neck ;  another,  which 
is  inferior,  and  deep,  belonging  particularly  to  the  thoracic  limb.  The 
cellular  and  adipose  tissues  are  abundant,  and  the  skin  which  surrounds 
all  these  organs  presents  nothing  peculiar. 

Development.  In  the  early  periods  of  fetal  existence,  there  is  no 
neck  :  the  young  embryo,  attached  to  the  umbilical  vesicle,  is  entirely 
abdomen  :  at  a  later  period,  a  circular  and  narrow  contraction  indicates 
its  place  :  it  rapidly  increases,  and  is  then  proportionally  longer  than 
in  the  adult.  At  puberty,  it  becomes  arched  anteriorly,  and  gradually 
grows  smaller  than  in  infancy.  In  the  old  man,  it  is  drawn  forward 
by  the  weight  of  the  head,  which  is  supported  with  difficulty  by  the 
posterior  muscles,  and  the  neck  is  concave  in  this  direction,  as  during 
fetal  existence :  at  this  age,  also,  the  motions  become  more  difficult,  on 


108  TOPOGRAPHICAL  ANATOMY. 

account  of  the  rigidity  of  the.  muscles  of  the  spine.  A  costiform*  epi- 
physis  forms  at  an  early  period  in  the  fetus,  in  front  of  each  transverse 
process  :  this  is  longer  on  the  last  vertebra :  this  piece  soon  fuses  with 
the  transverse  process,  and  forms  the  foramen  of  the  vertebral  artery. 

Varieties.  The  cervical  portion  of  the  trunk  is  sometimes  conside- 
rably long,  even  in  the  adult:  this  is  an  anomaly,  which  is  often 
attended  with  a  bad  formation  of  the  thorax,  and  which  is  therefore 
considered  as  the  sign  of  a  disposition  to  phthisis-  pulmonalis.  Some- 
times the  neck  is  very  short ;  another  anomaly,  which,  approximating 
the  chest  and  the  heart  to  the  head  and  the  brain,  disposes  sometimes 
to  cerebral  hemorrhage,  and  forms  one  of  the  characters  of  what  is 
termed  an  apoplectic  habit.  Sometimes  only  six  cervical  vertebrae  are' 
found,  and  never  more  than  seven  :f  in  the  former  case,  there  is  a 
supernumerary  rib.  These  two  irregular  arrangements  are  easily  un- 
derstood, by  supposing  that  the  costiform  process  of  the  seventh  .cervical 
vertebra  is  extended  in  the  form  of  a  rib  to  the  sternum.  Some  assert 
that  this  occurs  in  all  those  who  have  an  apoplectic  habit ;  but  our 
observations  have  proved  the  contrary. 

In  the  female,  the  neck  is  more  delicate  and  round  than  in  the  male: 
in  the  latter,  all  the  prominences  and  depressions  are  more  distinct. 

Finally,  in  the  motions,  the  extent  of  the  neck  varies  in  different 
parts:  thus,  in  flexion,  it  becomes  shorter  anteriorly,  and  extends 
posteriorly:  the  opposite  is  true  in  extension  :  hence  the  precept,  in 
operations  on  the  neck,  to  cause  the  patient  to  assume  such  a  position, 
that  the  part  operated  upon  must  be  opposed  to  the  motion  in  which 
the  whole  region  inclines. 

Pathological  and  operative  deductions.  The  arrests  of  development, 
supervening  at'  periods  more  or  less  near  that  of  conception,  explain 
the  different  deviations  in  the  formation  of  the  neck  ;  these  are  its 
entire  absence,  (abrachio-cephalia,  Beclard,)  a  monstrosity,  the  name 
of  which  merely  shows  the  simultaneous  absence  of  the  head  and  the 
thoracic  extremities,  the  last  not  being  formed,  perhaps  because  the 
brachial  bulb  of  the  medulla  did  not  previously  exist :  the  absence  of 
the  upper  half  of  the  neck  only,  (atrqchelo-cephalia,  Beclard.)  In  these 
latter  cases,  the  brachial  enlargement  of  the  medulla  exists  with  the 
corresponding  limbs. 

In  old  people,  and  young  children,  caries  often  affects  the  cervical 
portion  of  the  spine,  and  the  pus  formed  by  it  assumes  different  situa- 
tions, according  as  the  disease  affects  the  anterior  or  posterior  parts  of 

f  This  epiphysis  may  be  considered  as  analogous  to  the  cervical  ribs  of  some  animals, 
particularly  of  crocodiles. 

t  Only  one  mammal  has  more  than  seven  cervical  vertebrae,  the  bradypus  tridactylus,  which  ' 
has  nine. 


TRACHEAL    PORTION    OF  THE   NECK.  109 

the  spine.  If  the  medulla  be  wounded  or  compressed  in  the  neck,  by 
any  cause,  death  instantly  follows,  respiration  ceasing.  This  is  the 
reason  that  the  fractures  and  dislocations  of  the  cervical  vertebrae,  and 
certain  wounds,  are  so  serious.  Dislocations  of  the  first  two  vertebrae 
are  more  common  in  infancy  :  at  this  age,  they  are  sometimes  produced 
by  a  fall  on  the  head,  because  the  odontoid  process  being  shorter, 
projects  but  slightly  above  the  transverse  ligament,  behind  which  it 
passes  easily.  A  shock  upon  the  spinal  marrow,  in  certain  motions  of 
the  head  upward,  may  alone  cause  death,  as  was  seen  by  J.  L.  Petite 
once.  The  fear  of  injuring  the  medulla,  or  of  rendering  complete 
imperfect  dislocations  of  the  cervical  vertebrae,  should  always  prevent 
us  from  attempting  their  reduction. 

Such  are  the  general  remarks  upon  this  important  portion  of  the 
trunk :  it  is  composed  of  two  groups,  which  are  separated  by  the  spine ; 
an  anterior,  (trachelien,  Ch.)  and  a  posterior,  (cervical,  Ch.) 


ARTICLE        I. 


TRACHEAL   PORTION   OF   THE   NECK. 

Chaussier  applies  this  term  to  the  anterior  part  of  the  neck,  because 
it  contains  the  trachea :  it  may  also  be  called  the  pharyngeal  portion. 

We  remark,  externally,,  above  the  sternum,  a  considerable  median 
depression,  above  which  is  the  laryngo-tracheal  prominence,  which 
are  included  between  the  sterno-mastoid  muscles :  on  the  sides,  in  front 
of  these  two  prominences,  which  are  extended  from  below  upward, 
and  from  before  backward,  is  a  depression,  in  which  we  can  feel  the 
pulsations  of  the  carotid  artery :  while  backward  and  downward,  they 
bound  another  depression,  termed  the  supra-clavicular,  in  which  the 
pulsations  of  the  axillary  artery  can  be  felt. 

Structure, — 1.  Elements.  All  this  part  of  the  neck  rests  on  the 
anterior  face  of  the  spine :  a  portion  of  the  air-passage,  and  of  the 
digestive  tube,  belong  to  it,  with  all  the  cervical  lymphatic  ganglions : 
it  is  also  exclusively  the  seat  of  the  cervical  .aponeurosis,  although 
some  persons  confound  it  with  the  dense  cellular  tissue  which  exists 
posteriorly,  and  which  has  no  lamellar  arrangement. 

This  aponeurosis,  the  fascia  cervical,  (Burns,)  should  be  described 


110  TOPOGRAPHICAL    ANATOMY. 

when  treating  generally  of  the  tracheal  portion  of  the  neck,  because 
it  extends  to  every  point  of  this  portion,  and  our  idea  of  it  would  be 
imperfect,  if  we  divided  its  study  among  that  of  the  different  regions. 
Finally,  it  should  be  described  more  minutely,  because  this  part, 
although  extremely  important,  is  generally  unnoticed  in  treatises  on 
anatomy. 

Although  the  fascia  cervicalis  covers  the  whole  tracheal  face 
of  the  neck,  it  is  most  apparent  at  the  lower  part ;  here  also  it  is 
denser,  and  its  arrangement  is  more  complex ;  it  extends  from  above 
downward,  from  the  base  of  the  jaw  to  the  sternum,  and  to  the  clavicle ; 
its  lateral  boundaries  are  less  exact,  and  vary  in  different  parts, 
as  we  shall  see ;  this  aponeurosis  extends  superficially  to  the  skin  ; 
deeply,  it  rests  on  the  hyoid  muscles  and  the  trachea ;  it  adheres  very 
intimately  to  the  hyoid  bone,  and  the  larynx ;  at  these  parts  it  is 
simple,  but,  in  every  other  part,  above  or  below,  it  is  formed  of  at  least 
two  layers,  a  superficial  and  a  deep.  The  first  is  triangular,  unites 
with  the  other  in  the  place  mentioned,  and  connects  the  two  platysma 
muscles  from  above  downward  ;  it  commences  above  in  a  point  on  the 
jaw;  below,  it  glides  before  the  sterno-mastoid  muscles  and  the 
sternum,  and  soon  terminates  in  the  subcutaneous  tissue  of  the  thorax. 
The  second  passes  on  the  upper  part  below  the  platysma  muscles,  on 
the  outside  of  the  digastrici  muscles,  and  of  the  sub-maxillary  gland, 
and  terminates  at  the  lower  edge  of  the  jaw,  and  also  at  its  angle, 
being  continuous  with  the  stylo-maxillary  ligament :  inferiorly,  this 
second  layer  of  the  cervical  aponeurosis  is  situated  below  the  sterno- 
mastoid  muscles,  and  in  front  of  the  sterno-hyoid  and  thyroid  muscles, 
then  comes  downward  and  terminates  on  the  summit  of  the  sternum, 
and  on  the  posterior  edge  of  the  clavicle :  it  is  attached  laterally  to  the 
central  tendon  of  the  scapulo-hyoid  muscle,  and  keeps  it  in  its  position  ; 
we  must  not  blend  this  layer  with  the  dense  tissue  which  covers  the 
carotid  artery,  and  forms  its  sheath.  This  deep  layer  of  the  cervical 
aponeurosis  is  separated  from  the  trachea  and  the  thyroid  gland,  by 
the  sterno-hyoid  and  thyroid  muscles  ;  but,  on  the  outside  of  these,  it 
gives  off  downward  a  secondary  layer,  which  extends  between  these 
muscles  and  the  trachea  ;  this  layer  adheres  above  very  intimately  to 
the  lower  edge  of  the  thyroid  body,  and  is  continuous  below  with  the 
periosteum,  which  covers  the  posterior  face  of  the  sternum. 

The  cervical  aponeurosis  is,  in  fact,  composed  superiorly  of  two 
layers,  and  inferiorly  of  three ;  in  consequence  of  this  latter  arrange- 
ment, it  forms,  with  its  superficial  and  middle  layers,  a  special  sheath 
for  the  lowerpart  of  the  sterno-mastoid  muscles,  while  the  last  and 
third  layer,  which  is  very  dense,  envelopes  the  small  infra-hyoid 
muscles. 


TRACHEAL  PORTION  OF  THE  NECK.  .      Ill 

The  tracheal  position  of  the  neck,  as  we  have  remarked,  is  occupied 
above  by  the  pharynx,  a  kind  of  expansion  of  the  digestive  tube,  the 
special  description  of  which,  does  not  belong  to  our  subject,  but  the 
topography  must  be  stated  here,  because  it  corresponds  to  several  of 
the  regions  which  we  shall  soon  examine  in  detail.  This  complex 
organ,  or  this  pharyngeal  region,  has  no  special  wall  anteriorly ;  in 
this  direction,  it  is  formed  successively  from  above  downward,  by  the 
palatine,  the  glosso-supra-hyoid,  and  the  laryngo-tracheal  regions;  it 
is  open  in  three  points,  to  communicate  with  the  nostrils,  the  mouth, 
and  the  larynx.  Posteriorly,  and  on  the  sides,  however,  the  pharynx 
has  proper  parietes,  which  are  formed  from  without  inward,  by  a  layer 
of  muscular  fibres,  a  dense  cellular  tissue,  and  a  very  follicular  mu- 
cous membrane. 

The  pharyngeal  region  is  bounded  posteriorly  by  the  longus  colli 
and  the  anterior  rectus  capitis  muscles,  from  which  it  is  separated  by 
a  lamellar  and  very  loose  cellular  tissue  ;  by  means  of  these  parts  it 
corresponds  to  the  anterior  face  of  the  spine,  at  the  first  five  cervical 
vertebrae,  and  also  to  the  rectus  capitis  anticus  minor,  which  is  situated 
under  the  reetus  major.  Forward  and  on  the  outside  the  pharynx  is 
connected  with  several  cervical  regions,  as  we  shall  state  hereafter. 
Above,  it  is  united  by  the  cephalo-pharyngeal  aponeurosis,  to  the  lower 
face  of  the  basilar  portion  of  the  base  of  the  skull.  Besides  its  com- 
munication with  the  cavities  of  the  nostrils,  the  mouth,  and  the  larynx, 
the  cavity  of  the  pharynx  is  continuous  inferiorly  with  the  esophagus ; 
the  Eustadhian  tubes  also '  come  to  it  in  the  parts  mentioned.  The 
velum  palati,  when  it  is  elevated  horizontally,  divides  the  cavity  of  the 
pharynx  into  two  portions,  a  superior,  the  gutturo-olfactory,  and  an 
inferior,  the  bucco-laryngoeal :  and  then,  also,  we  can  observe  in  the 
mouth  the  loose  face  of  the  posterior  wall  of  the  pharynx,  its  rosy  color, 
and  the  follicular  granulations  which  cover  it :  these  will  be  seen  more 
clearly  by  depressing  the  base  of  the  tongue  at  the  same  time.  The  di- 
mensions of  the  cavity  of  the  pharynx  are  highly  important ;  its  height  is 
four  inches  and  three  lines ;  its  antero-posterior  diameter  diminishes  pro- 
gressively from  above  downward,  in  the  state  of  rest,  and  also  varies 
continually,  during  the  contraction  of  the  pharyngeal  muscles ;  the 
mean  measure  of  this  diameter,  at  the  base  of  the  tongue,  is  one  inch 
and  five  lines  ;  the  transverse  diameter  does  not  decrease  in  the  same 
proportion  as  the  preceding ;  farther,  it  is  always  the  same  in  two 
points  ;  first,  at  the  opening  of  the  nasal  fossae  ;  second,  between  the 
horns  of  the  hyoid  and  thyroid  cartilages  ;  in  the  former  point,  it 
measures  an  inch  and  a  half,  and  one  inch  and  nine  lines  in  the 
latter. 

Uses.    The  pharynx  forms  a  kind  of  vestibule,  common  to  the  air- 


112  TOPOGRAPHICAL  ANATOMY. 

passages  and  digestive  apparatus  ;  sometimes,  as  in  deglutition,  its 
uses  relate  exclusively  to  the  latter ;  sometimes,  as  in  respiration,  to 
the  former.  During  articulation,  the  velum  palati  rises,  and  prevents 
all  communication  between  the  upper  and  lower  portions  of  the 
pharynx :  the  air  cannot  then  enter  into  the  nasal  fossae ;  when  the 
air  passes  into  these  parts,  the  tone  is  nasal.*  The  cervical 
aponeurosis  being  extended  on  this  portion  of  the  neck,  renders  it  very 
resisting,  and  prevents  the  trachea,  in  deep  inspirations,  from  being 
compressed  by  the  external  air,  which  tends  to  form  an  equilibrium 
with  the  internal  rarefied  air.  The  depression  above  the  sternum, 
which  is  so  distinct  in  difficult  respiration,  is  explained  by  this  theory. 

Pathological  and  operative  deductions.  Wounds  of  the  neck 
may  be  complicated  with  penetrating  wounds  of  the  trachea  and  di- 
gestive passages  ;  hence  result  fistulas  of  different  characters  :  hence, 
also,  infiltrations  of  air  which  constitute  emphysema.  The  uses  of  the 
cervical  aponeurosis- in  respiration,  explain  the  difficulty  of  respiration 
in  individuals,  in  whom  it  has  been  affected  by  wounds,  or  by  the 
progress  of  an  abscess.  The  tumors  which  are  developed  on  the  out- 
side of  this  fascia'  go  towards  the  skin  ;  those,  on  the  contrary,  which 
are  situated  under  it,  penetrate  deeply  toward  the  air-passages  and 
digestive  apparatus,  impede  respiration  and  deglutition,  and,  a  priori, 
it  is  impossible  to  judge  of  their  size  ;  finally,  those  which  appear 
between  its  lower  layers,  present  mixed  characters. 

The  anterior  abscesses  of  the  neck  generally  proceed  like  other 
tumors  in  this  great  region,  their  progress  is  modified  by  their  position 
relative  to  the  aponeurosis :  those  which  are  situated  deeply,  have  a 
peculiar  tendency  to  point  in-  the  chest,  which  termination  is  facilitated 
by  the  laxity  of  the  anterior  cellular  tissue. 

The  almost  immediate  relations  of  the  spine  and  pharynx,  explain 
the  opening  into  the  throat  of  some  abscesses,  resulting  from  the  caries 
of  the  vertebrae,  and  reciprocally  the 'affection  of  the  latter  consequent 
upon  diseases  of  the  pharynx.  We  have  seen  a  purulent  tumor  de- 
veloped between  the  pharynx  and  the  spine,  which  impeded  deglu- 
tition, until  it  pointed  in  the  former.  Farther,  all  these  diseases,  with 
swelling  of  the  regions  which  surround  the  pharynx,  may  contract  it,; 

*  This  explanation  of  the  quality  of  the  voice,  given  by  Magendie,  is  contrary  to  the 
generally  .received  opinion  of  Haller ;  but,  we  think  it  preferable.  It  is  also  confirmed  by  the 
following  experiment :  place  yourself  before  a  candle,  a  sheet  of  paper  being  interposed  be- 
tween the  nose  and  mouth,  prevent  the  air  from  the  mouth  from  agitating  it,  and  observe 
what  takes  place :  when  the  sounds  formed  are  of  the  usual  quality,  the  flame  is  motionless, 
but  is  constantly  agitated  if  you  attempt  to  speak  through  the  nose.  The  experiment  suc- 
ceeds still  better^jf  you  place  under  the  nose  a  very  volatile  powder,  it  is  raised  only  in  the 
second  case ;  we  must  be  careful  not  to  mistake  the  agitation  of  the  light,  or  of  the  powder 
during  inspirations,  if  these  experiments  are  continued  for  anytime. 


TRACHEAL  PORTION  OP  THE  NECK.  .          113 

and  thus  render  the  deglutition  and  respiration  difficult.  Polypi  of 
the  nasal  fossae  sometimes  proceed  towards  this  region,  crowd  back 
the  velum  palati,  and  prevent  it  from  perfectly  closing  the  posterior 
cavity  of  the  nostrils ;  hence  a  nasal  tone,-  and  even  a  difficulty  in 
deglutition.  The  division  of  the  velum  palati  causes  the  same  phe- 
nomena, because  it  is  thus  rendered  unfit  for  its  normal  functions,  in 
regard  to  the  larynx.  Instruments  are  introduced  into  the  pharynx 
to  remove  foreign  bodies,  or  to  sound  the  pharynx  and  the  esophagus. 
We  shall  mention  the  catheterism  of  the  first  again  :  to  perform  the 
second  with  ease,  we  must  glide  the  instrument  against  the  posterior 
wall  of  the  cavity- 

Division.  The  tracheal  portion  of  the  neck  comprises  so  many 
organs,  the  functions  of  these  are  so  intimately  connected  with  the 
support  of  life,  and  this  part  of  the  body  is  so  important  in  respect  to 
surgical  operations,  that  it  cannot  be  studied  too  minutely ;  hence,  we 
must  examine  it  successively,  in  detached  spaces,  which  do  not  always 
have  natural  bounds :  this  latter  condition,  however,  is  impossible  in 
some  -points.  After  reflecting  maturely  on  this  subject,  we  have  con- 
cluded that  the  difficulty  may  be  avoided  in  two  ways,  which  are  not 
equally  good :  First,  by  including  all  the  regions  of  the  neck  within 
arbitrary  limits  ;  second,  by  forming  artificial  regions  only  where  they 
can  be  traced  in  no  other  manner  ;  then,  in  following  this  latter  prin- 
ciple, to  group  the  relations  of  the  adjacent  parts  around  an  important 
organ,  which  shall  give  its  name  to  the  region.  This  last  mode  seems 
preferable,  and  it  was  that  chosen  "by  Beclard,  for  his  divisions  of  the 
neck,  when  lecturing  on  topographical  anatomy.  Some  of  the  regions 
thus  formed  will  be  entirely  natural,  and  others  slightly  artificial. 
The  following  table,  formed  on  these  principles,  will  give  an  idea  of 
our  division  of  the  tracheal  portion  of  the  neck :  the  practical  impor- 
tance of  this  division  will  not  be  questioned. 

£  fe  M-  f  Natural  regions.  .  ,       .  (  Ab°7,e, the   j  Jn  ^  cen*re  . .  .  Glosso-supra-hyoid  region. 

2  "  o  I  hyoid  bone.  (  On  the  sides  .  .  .  Parotid  region. 

5  o  %  1  ]  Below  the    ( In  the  centre  .  .  .  Laryngo-tracheal  region, 

5|  h  w -|  I  hyoid  bone.  {  On  the  sides  .  .  .  Supra-clavicular  region. 

Bog     Artificial  regions (  The  Sterno-mastoid  muscle. .  Sterno-mastoid  region. 

*  H   [Groups  formed  around.  ^  The  Carotid  artery  .  . , Carotid  region. 


15 


114  TOPOGRAPHICAL  ANATOMY. 


PARAGRAPH        FIRST. 


NATURAL  REGIONS  OF  THE  ANTERIOR  TART  OF  THE  NECK. 

These  regions  are  four:  some  are  unmated  and  symmetrical,  and 
are  situated  on  the  median  line ;  others  are  mated,  are  unsymmetrical, 
and  are  placed  on  the  sides :  the  hyoid  bone  separates  them  into  two 
groups,  an  upper  and  a  lower. 


ORDER     FIRST. 

NATURAL    REGIONS    OF    THE    SUPRA-HYOID    PART    OF    THE    NECK. 

These  regions  connect  anteriorly  the  neck  and  the  head :  they  are 
two  in  number  :  the  supra-hyoid,  and  the  parotid. 


1.       SUPRA-HYOID,      OR      GL  OS  S  O-S  U  P  R  A-H  Y  O  I  D      REGION. 

This  region  is  circumscribed  above,  by  the  inferior  edge  of  the 
maxillary  bone  ;  below,  by  the  hyoid  bone ;  and  laterally,  by  a  fictitious 
line,  drawn  between  the  angle  of  the  jaw  and  the  extremity  of  the 
great  horn  of  the  hyoid  bone :  it  is  unmated,  symmetrical,  situated  on 
the  median  line,  and  forms,  if  we  include  the  tongue,  the  floor  of  the 
mouth  and  a  part  of  the  anterior  wall  of  the  pharynx :  for  this  double 
purpose  it  is  also  directed,  so  that  its  horizontal  anterior  portion  forms 
with  the  posterior  vertical  part  a  rounded  and  obtuse  angle  :  it  is  ter- 
minated by  two  faces  :  one  of  these  is  cutaneous,  and  covered  with 
very  coarse  hair  in  the  adult  male,  and  presents  in  fat  individuals  one 
or  more  transverse  prominences,  which  give  the  appearance  of  a  double 
chin ;  the  other  is  mucous,  pharyngoeal  at  its  posterior  part,  and  presents 
in  this  direction,  the  glandular  base  of  the  tongue,  the  frenum  of  the 
epiglottis,  and  two  lateral  mucous  depressions :  it  is  buccal  anteriorly, 
and  also  presents  nearly  the  whole  tongue,  except  at  the  anterior  part, 
where  the  tongue  is  detached,  and  leaves  a  crescent-formed  space, 
which  is  convex  anteriorly.  We  find  there,  on  the  median  line,  the 
frenum  of  the  tongue ;  near  it,  two  small  prominences,  in  which  the 
duct  of  Wharton  opens  on  each  side ;  and  finally,  from  this  point,  a 
line,  which  is  directed  obliquely  backward  and  outward:  this  marks 
the  passage  of  Wharton. 


GLOSSO-SUPRA-HYOID  REGION.  .          115 

Structure.  —  1.  Elements.  The  supra-hyoid  region  has  no  skeleton : 
it  is  circumscribed  by  the  prominences  of  the  inferior  maxillary  arid  hyoid 
bones ;  but  they  do  not  belong  to  it :  we  find  there,  also,  many  muscles, 
the  platysmata  converging  toward  each  other,  and  often  united  above,  by 
a  transverse  fasciculus  ;  the  anterior  belly  of  the  digastrici  muscles,  the 
mylo-hyoidei,  which  unite  and  form  a  complete  and  contractile  floor, 
the  genio-hyoidei  and  genio-glossi,  the  hyo-glossi,  the  lingualis,  a  portion 
of  the  stylo-glossus,  and  the  special  fleshy  fibres  of  the  tongue.*  A 
very  strong  aponeurosis  belongs  particularly  to  this  region :  it  is  tri- 
angular, and  is  inserted  on  the  hyoid  bone  and  the  two  tendons  of  the 
digastrici  muscles,  and  is  continuous  with  their  pulley.  A  layer  of  the 
cervical  aponeurosis  unites  the  two  platysma  muscles  upon  the  median 
line  :  we  also  find,  under  these  latter,  a  dense  cellule-fibrous  layer,  the 
superior  deep  layer  of  the  preceding  aponeurosis.  This  latter  passes 
below  the  sub-maxillary  gland  and  its  vessels,  is  attached  to  the  lower 
edge  and  to  the  angle  of  the  jaw,  continuing  with  the  stylo-maxillary 
ligament,  so  as  to  form  a  much  more  distinct  line  of  demarcation  be- 
tween the  parotid  and  sub-maxillary  glands  than  is  generally  admitted. 
The  arteries  of  this  section  of  the  neck  are  very  numerous :  a  consi- 
derable tortuous  branch  passes  through  it,  following  the  course  of  a 
line  drawn  from  the  hyoid  bone  toward  the  anterior  edge  of  the  mas- 
seter  muscle  :  this  artery  is  the  facial,  which  sends  off  in  its  course 
several  important  branches  into  the  elements  of  this  region :  one  of 
these  forms  the  sub-mental  artery,  another  the  inferior  palatine  artery, 

*  We  have  ascertained  that  the  tongue  is  not  an  inextricable  mass,  according  to  the  ex- 
pression of  anatomists,  and  that  it  is  formed  :  first,  of  a  median  cartilage,  analogous  to  the 
lingual  prolongation  of  the  hyoid  bone  of  birds,  a  cartilage  very  much  developed  in  man,  and 
deficient  in  some  animals,  and  which  must  not  be  blended  with  a  production  of  the  same  kind 
which  exists  loosely  under  the  mucous  membrane  of  the  tongue  of  the  dog,  the  wolf,  the  bear, 
&c. ;  second,  of  a  mucous  membrane,  the  detma  of  which  is  extremely  strong,  which  serves, 
with  the  median  cartilage,  for  the  insertion  of  all  the  fleshy  fibres,  the  mucous  body  of  which 
presents  small  secretory  organs,  and  numerous  eminences,  termed  collectively,  the  papilla  ; 
some  of  these  are  lenticular,  others  conical,  a  third  kind  fungiform,  and  a  fourth  species, 
form  the  V  of  the  tongue :  the  latter  are  composed  of  fungiform  papillae,  which  are 
very  much  developed,  and  arise  from  the  base  of  a  small  cavity  or  follicle  :  third,  of  intrinsic, 
transverse,  and  longitudinal  fibres,  which  are  few  in  the  male,  but  have  been  observed  in 
animals  by  Gerdy  :  fourth,  of  extrinsic  fleshy  fibres,  among  which,  the  perpendicular  come 
from  the  genio-glossus  ;  the  others,  which  are  longitudinal,  come  from  the  hyo-glossus,  on 
the  edges  and  upper  face  ;  inferiorly,  from  the  stylo-glossus :  finally,  some  which  are  trans- 
verse, arise  from  a  fasciculus  of  the  stylo-glossus.  If  we  divide  a  tongue  perpendicularly 
and  transversely,  we  can  see  that  the  longitudinal  fibres  exist  in  every  part  under  the  mucous 
membrane,  and  that  the  perpendicular  and  transverse  fibres  are  situated  in  the  centre  with 
the  median  cartilage. 

Finally,  we  have  described  a  glosso-hyoid  membrane,  which  is  peculiar  to  man,  and  attaches 
the  tongue  to  the  body  of  the  hyoid  bone ;  and  also  two  lingual  glands,  situated  under  the 
fimbriated  fold  of  the  lower  face  of  the  organ,  and  covered  directly  by  the  lingualis  muscle 
and  the  long  fasciculus  of  the  stylo-glossus  muscle. 


116  TOPOGRAPHICAL   ANATOMY. 

while  many  others  have  not  received  distinct  names  :  another  branch 
of  the  external  carotid  artery,  the  lingual  artery,  is  situated,  like  the 
facial,  in  the  supra-hyoid  region,  and  does  not  quit  it;  it  is  first  situ- 
ated inferiorly,  and  proceeds  parallel  to  the  great  horn  of  the  hyoid 
bone,  then  ascends  perpendicularly  into  the  perpendicular  portion  of 
the  region,-and  finally  again  becomes  horizontal  anteriorly ;  we  must 
not  omit  to  mention  the  large  branch  which  is  detached  from  it,  and 
forms  the  middle  artery  of  the  region,  the  sub-lingual,  which  some- 
times gives  off  the  sub-mental  artery,  and  sometimes  arises  from  it. 
The  veins  in  this  part  are  rather  more  superficial  than  the  arteries : 
thus,  the  lingual  vein  passes  on  the  outside  of  the  hyo-glossus  muscle  : 
with,  this  exception,  they  follow  their  course.  Numerous  lymphatic 
ganglions  exist  around  the  sub -maxillary  gland,  the  sub-maxillary  lym- 
phatic vessels  :  besides  the  lymphatic  vessels  of  the  region,  they  receive 
all  those  of  the  face.  The  nerves  are  superficial,  middle,  and  deep  :  the 
first  are  given  off  by  the  superficial  cervical  plexus,  and  by  the  facial 
nerve  ;  the  second  belong  to  the  mylo-hyoid  twig  of  the  inferior  dental 
nerve ;  the  last,  the  lingual,  come  from  the  hypo-glossal,  the  lingual, 
the  glosso-pharyngoeal,  and  the  branches  of  these  trunks.  The  cellular 
tissue  of  this  region  is  very  loose,  except  under  the  skin  :  it  contains  a 
little  fat,  deeply,  but  fat  is  more  common  superficially,  around  the  sub- 
maxillary  gland. 

2,  Relations.  The  relations  of  the  numerous  organs  of  this  region 
ought  to  be  studied,  first  on  the  median  line  in  the  sub-mental  portion, 
then  on  the  sides,  around  the  sub-maxillary  gland. 

1.  We  find  on  the  median  line,  from  the  skin  toward  the  mucous  mem- 
brane, which  are  the  two  extreme  parts  of  the  region  ;  a  celmlo-fatty 
layer,  in  which  the  quantity  of  fat  varies ;  next,  the  platysma  muscles, 
which  are  united  by  the  cervical  aponeurosis,  then  within  them  or  under 
them  the  superficial  nerves  and  some  branches  of  the  sub-mental  artery ; 
we  then  find  another  layer,  formed  by  the  anterior  belly  of  the  digas- 
trici  muscles,  and  by  the  aponeurosis  which  unites  them  inferiorly ;  un- 
der this  some  deep  twigs  of  the  sub-mental  artery,  which  cover  another 
plane  formed  by  the  mylo-hyoidei  muscles  united  by  a  raphe,  and  par- 
tially attached  inferiorly  to  the  fibrous  membrane  of  the  preceding 
layer.     The  mylo-hyoidei  muscles  being  turned  over,  we  perceive  the 
two  genio-hy'oidei  muscles;  below,  the  genio-glossi  muscles,  and  finally, 
still  more  deeply,  upward  and  forward,  the  mucous  membrane  of  the 
floor  of  the  mouth,  a  prolongation  of  the  sub-lingual  gland,  and  of  the 
duct  of  Wharton :   downward  and  backward,  the  tongue,  through 
which  we  mustvpass  before  coming  into  the  mouth  or  the  pharynx. 

2.  On  the  sides,  from  the  skin  towards  the  mucous  membrane,  we  find  ; 
first,  as  on  the  median  line,  the  sub-cutaneous  cellular  layer,  and  the 


GLOSSO-SUPRA-HYOID  REGION.  •        117 

platysma ;  but  the  parts  under  this  differ ;  first  comes  a  cellulo-fibrous 
layer,  attached  on  the  edge  and  the  angle  of  the  jaw ;  next  a  net-work 
formed  by  the  vein,  the  facial  arteries,  and  their  sub-maxillary  branches, 
some  lymphatic  vessels  of  the  face,  the  mylo-hyoid  twig  of  the  infe- 
rior dental  nerve,  the  inferior  twigs  of  the  facial  nerve,  and  the  super- 
ficial cervical  nerves  of  the  cervical  plexus,  in  which  net-work  nearly 
the  whole  sub-maxillary  gland,  and  many  lymphatic  ganglions  are  im- 
bedded. We  observe  in  this  plexus,  that  the  veins  are  superficial,  that 
the  trunk  of  the  facial  vein  passes  on  the  outside  of  the  gland,  while 
that  of  the  artery  is  situated  on  the  inside  of  it,  or  within  it ;  that  the  sub- 
mental  artery  follows  the  lower  edge  of  the  maxillary  bone  which  pro- 
tects if;  finally,  that  the  mylo-hyoid  nerve  is  situated  still  more  deeply 
under  the  gland.  All  these  parts  being  removed,  the  mylo-hyoideus 
muscle  is  exposed,  its  external  edge  extends  but  a  short  distance,  and 
we  see  on  the  outside  of  it  a  part  of  the  next  layer,  which  on  the  in- 
side lies  under  the  mylo-hyoideus  muscle  ;  this  plane  is  formed,  upward 
and  forw  ard,  by  a  prolongation  of  the  sub-maxillary  gland,  by  the  sub- 
lingual  gland,  the  duct  of  Wharton,the  lingual  nerve,  and  the  sub-lingual 
artery,  which  are  situated  below  them ;  all  these  parts  are  confined  by 
the  mucous  membrane  of  the  floor  of  the  mouth  ;  downward  and  back- 
ward, by  the  stylo-glossus  and  hyo-glossus  muscles,  this  latter  forming 
with  the  genio-glossus  a  cellular  interstice,  where  the  last  two  por- 
tions of  the  lingual  artery  are  situated,  and  in  which  the  great  hypo- 
glossal  nerve  terminates.  On  the  outside  of  the  hyo-glossus  muscle, 
we  find  upon  it  the  preceding  nerve,  and  the  lingual  vein,  which  pro- 
ceed parallel  to  the  horn  of  the  hyoid  bone,  and  likewise  the  lingual 
artery,  and  the  glosso-pharyngoeal  nerve,  which  are  situated  more 
deeply ;  these  last  parts  rest  directly  against  the  body  of  the  tongue, 
through  which  we  must  pass,  as  on  the  median  line,  to  come  into  the 
pharynx  or  the  mouth. 

Varieties.  In  the  child  this  region  is  always  convex,  because  there 
is  an  -abundance  of  fat  under  the  skin ;  this  afterward  diminishes,  and 
then  the  arched  appearance  of  the  region  mostly  disappears ;  finally, 
about  the  forty-fifth  year,  the  fat  again  accumulates  under  the  skin, 
depresses  it,  and  forms  the  prominences  which  we  have  already  men- 
tioned. 

In  the  adult  male,  the  beard  appears  upon  this  region ;  in  the  female 
this  region  is  always  smooth,  and  as  round  as  in  infancy. 

The  varieties  of  the  organs  of  this  region  are  few:  they  appear  prin- 
cipally in  the  sub-lingual  artery,  which  may  arise  more  superficially 
than  in  the  normal  state ;  it  may  come,  for  instance,  from  the  sub-men- 
tal-artery, and  then  it  passes  through  the  fasciculi  of  the  hyo-glossus 
muscle.  The  stylo- hyoideus  muscle  frequently  is  not  bifurcated  at  the 


118  TOPOGRAPHICAL  ANATOMY. 

lower  part ;  we  often  find  an  abnormal  muscle  in  the  place  of  the  stylo- 
hyoid  ligament;  the  latter  also  may  be  partially  or  entirely  ossified. 

The  direction  and  dimensions  of  this  region  are  varied  by  the  mo- 
tions of  the  hyoid  bone  ;  when  this  bone  is  elevated,  the  region  is 
shortened,  particularly  in  its  vertical  portion  ;  the  opposite  occurs  when 
the  bone  is  depressed. 

Pathological  and  operative  deductions.  Wounds  of  the  supra- 
hyoid  space  may  become  serious  when  they  are  lateral ;  in  fact,  in 
that  part,  the  facial  artery  and  the  sub-maxillary  gland  may  be  injured  ; 
these  accidents  may  cause  a  hemorrhage  or  salivary  fistula.  When 
the  lower  part  is  wounded,  particularly  by  an  instrument  acting  hori- 
zontally, the  pharynx  may  be  affected.  Wounds  of  the  upper  part, 
when  caused  by  the  perpendicular  action  of  a  wounding  agent,  may 
communicate  with  the  mouth.  If  the  lingual  artery  has  been  wounded, 
it  may  be  tied  under  the  hyo-glossus  muscle,  near  the  great  horn  of  the 
hyoid  bone,  by  making  a  small  incision  parallel  to  the  bone,  which  is 
easily  felt ;  in  this  operation  we  divide  the  skin,  the  platysma,  raise 
the  digastricus  and  the  stylo-glossus,  and  the  hyo-glossus  will  be  in- 
terested ;  the  artery  -being  exposed  can  easily  be  seized  by  a  director ; 
we  must  not  operate  too  far  from  the  horn  of  the  hyoid  bone,  lest  the 
great  hypo-glossal  nerve  be  injured  ;  this  operation  is  easily  performed 
on  the  cadaver,  and  its  inventor,  Beclard,  recommends  it  in  cases  of 
erectile  tumors  of  the  tongue,  or  where  a  cancerous  portion  of  this 
organ  is  to  be  removed.  Abscesses  of  this  region  sometimes  open  in 
the  mouth,  ulcerating  through  the  mucous  membrane ;  these,  however, 
are  situated  above  the  mylo-hyoideus  muscle  ;  those,  on  the  contrary, 
which  rest  on  its  lower  face,  point  toward  the  skin  ;  tumors  of  different 
characters  are  often  developed  there  on  the  outside,  and  are  rarely  situ- 
ated in  the  sub-lingual  gland ;  they  often  result  from  the  symptomatic 
engorgement  of  the  ganglions  which  surround  this  gland,  which  en- 
gorgement may  supervene  in  diseases  of  the  face  and  of  the  lateral 
regions  of  the  cranium,  and  of  the  head.  In  ranula,  the  tumor  formed 
by  the  dilatation  of  the  duct  of  Wharton  appears  in  this  part,  the  cir- 
culation of  the  saliva  being  impeded.  This  tumor  is  developed  at  first 
only  at  the  upper  part,  and  raises  the  mucous  membrane  under  which 
it  is  directly  situated  ;  but  a  long  time  elapses  before  it  depresses  the 
region  at  the  lower  part,  as  several  authors  have  stated.  The  cathe- 
terism  of  the  passage  of  Wharton,  when  this  passage  is  obstructed,  is 
difficult,  but  it  can  be  accomplished ;  it  will  not,  however,  cure  the  patient ; 
in  most  cases  an  operation  is  required,  which  consists  in  removing  the 
whole  anterior,, part  of  the  pouch.  A  great  portion  of  this  should  be 
removed,  unless  we  wish  the  wound  to  close  promptly  and  the  disease 
to  reappear ;  as  Dupuytren  advises,  the  fistulous  passage  may  be  kept 


PAROTID  REGION.  119 

open  with  a  double-headed  stylet.  In  the  bold  and  often  fortunate 
attempts  at  amputation,  and  even  in  the  extirpation  of  the  lower  jaw, 
successfully  performed  by  Dupuytren,  Delpech,  Grafe  of  Berlin,  the 
whole  of  this  region  must  be  detached  from  the  lower  jaw ;  if  the 
centre  of  the  bone  alone  is  to  be  removed,  the  facial  artery  is  uninjured, 
and  we  divide  only  the  twigs  of  the  sub-mental  and  sub-lingual 
arteries ;  the  trunk  of  the  first,  which  rests  closely  on  the  bone,  is 
generally  divided.  Finally,  it  is  on  the  mucous  face  of  this  region 
that  we  pass  through  the  mouth  and  the  larynx,  the  laryngoeal  tube 
of  Chaussier,  or  any  other  instrument,  destined  to  be  introduced  into 
the  larynx ;  when  it  arrives  at  the  base  of  the  epiglottis,  in  one  of  the 
lateral  mucous  depressions  which  we  have  pointed  out,  it  is  carried  a 
little  outward  and  backward,  and  thus  avoiding  the  epiglottis,  it  passes, 
with  facility  through  the  upper  opening  of  the  larynx.  Such  is  the 
mechanism  by  which  the  surgeon  introduces,  foreign  bodies  into  the 
air-passages  ;  but,  if  left  to  themselves,  they  will  not  follow  this  same 
course,  in  deglutition  for  instance ;  if  this  were  the  case,  opportunities 
of  observing  this  passage  would  be  much  more  common  ;  the  dispo- 
sition of  the  laryngoeal  valve,  which  is  depressed  from  before  backward, 
always  prevents  this  passage :  on  the  contrary,  in  order  that  a  foreign 
body  may  penetrate  into  the  larynx  during  deglutition,  it  must  pass 
below  the  level  of  this  part,  and  that,  by  a  movement  opposite  to  deglu- 
tition, it  is  carried  up  below  the  epiglottis,  which  cannot  then  prevent 
its  introduction. 


2.     PAROTID       REGION. 

This  region  is  mated  and  not  symmetrical,  and  occupies  the  lateral 
and  superior  parts  of  the  neck  ;  it  is  included  in  the  parotid  osseous 
space,  and  is  bounded :  anteriorly,  by  the  posterior  edge  of  the  ramus 
of  the  maxillary  bone ;  posteriorly,  by  the  mastoid  process  and  the 
auditory  passage ;  superiorly,  by  the  zygomatic  arch  ;  inferiorly,  by  a 
line  drawn  horizontally  backward,  to  the  level  of  the  angle  of  the  jaw  5 
on  the  inside,  deeply,  by  the  styloid  process,  its  stylo-maxillary  and 
hyoid  ligaments,  and  the  anatomical  bouquet  of  Riolan,  viz.  the  union 
of  the  muscles  and  ligaments,  which  are  attached  to  the  styloid  process 
of  the  temporal  bone.  Its  height  is  measured  by  the  length  of  the 
ramus  of  the  maxillary  bone  ;  its  breadth  varies  ;  the  mechanism  of 
the  jaw  is  such,  that  when,  this  bone  is  elevated,  its  breadth  is  in- 
creased above  and  diminished  below  ;  the  opposite  motion  is  attended 
with  an  opposite  change. 

The  cutaneous  face  of  this  region  presents  only  short  hairs,  and  is 


120  TOPOGRAPHICAL     ANATOMY. 

marked  by  a  depression  which  is  extremely  evident  in  thin  individuals 
the  hairs  of  the  face,  which  form  the  beard,  suddenly  cease  iii  front 
of  it. 

Structure.  —  1.  Elements.  The  parotid  region  has  no  resisting 
part,  it  rests  only  on  the  styloid  process  and  the  ligaments,  which 
extend  it  toward  the  jaw  and  the  hyoid  bone  ;  this  is,  properly  speak- 
ing, its  skeleton  ;  the  edge  of  the  ramus  of  the  jawjits  articulation,  the 
mastoid  process  and  the  auditory  passage,  which  are  its  limits,  belong 
to  it  in  part ;  the  same  is  true  of  the  styloid,  the  sterno-mastoid,  and 
the  digastric  muscles  ;  the  first  bound  it  on  the  inside,  the  others  back- 
ward and  downward.  The  platysma  is  the  only  muscle  which  truly 
extends  into  this  region,  although  to  a  slight  -extent;  the  parotid 
gland,  which  fills  it,  is  the  most  important  organ,  around  which  all 
the  others  should  be  grouped,  in  order  to  study  their  relations;  it 
always  emerges  a  little  anteriorly  from  the  region,  extends  into 
the  malar  region,  embracing  the  ramus  of  the  jaw ;  it  never  extends 
on  the  inside  beyond  the  edge  of  the  styloid  process,  and  the  edge  of  the 
sterno-mastoideus  posteriorly,  although  anatomists  assert  this  ;  its  con- 
tinuity with  -the  sub-maxillary  region  is,  as  has  already  been  said, 
prevented  by  a  fibrous  membrane  attached  to  the  angle  of  the  jaw.  A 
number  of  very  small  ducts  arise  from  all  its  granulations  and  form 
the  radicles  of  the  duct  of  Steno,  which,  however,  is  not  situated  in 
this  region.  The  parotid  arteries  are  numerous ;  all  arise  from  the 
external  carotid  artery,  which  is  situated  more  deeply  at  the  lower 
part,  and  more  superficially  at  the  upper ;  its  principal  branches, 
which  belong  to  this  region,  are  the  temporal  and  the  internal  maxil- 
lary artery  above,  the  transverse  facial  artery  anteriorly,  the  auricular 
arteries  posteriorly,  all  of  which  emerge  soon  after  arising,  and  finally 
some  small  twigs  which  are  distributed  in  the  parotid  gland  and  come 
from  the  external  carotid  artery  or  from  the  preceding  branches  ;  the 
veins  follow  the  course  of  the  arteries,  with  this  exception,  that  the 
principal  venous  trunk  is  more  superficial  than  the  artery.  This  vein 
forms  the  origin  of  the  external  jugular  vein,  and  sends  an  anasto- 
mosing branch  toward  the  internal.  We  also  find  numerous  lymphatic 
ganglions,  which  are  normally  very  small ;  they  receive  the  lymphatic 
vessels  of  the  temporal,  malar,  auricular  and  parotid  regions  ;  farther, 
these  ganglions  are  continuous  with  the  lateral  ganglions  of  the  neck. 
The  nerves  are  superficial  or  deep-seated  ;  the  first  belong  to  the  auri- 
cular branch  of  the  superficial  and  cervical  plexus,  which  branch  is 
not  distributed  entirely  in  the  ear,  as  its  name  would  indicate ;  the 
deep-seated  are  the  facial  nerve  and  its  diverging  cervical,  facial,  and 
temporal  filaments,  which  become  more  and  more  superficial  as  their 
distance  from  the  primitive  trunk  increases  ;  after  leaving  the  stylo- 


PAROTID  REGION.  .  121 

mastoid  foramen  this  trunk  proceeds  obliquely  downward.  Finally, 
the  superficial  temporal  filament  of  the  inferior  maxillary  nerve,  passes 
through,  at  the  upper  part,  the  whole  region,  describing  a  plexus  con- 
cave superiorly,  which  embraces  the  zygomatie  arch  and  the  temporo- 
maxillary  articulation.  The  sub-cutaneous  cellular  tissue  is  dense 
and  contains  but  very  little  fat ;  the  deep  tissue  which  forms  the  inter- 
lobular  tissue  of  the  parotid  gland  is  also  very  dense  but  never 
adipose. 

2.  Relations^  In  recomposing  the  parotid  region,  which  we  have 
analyzed,  we  shall  find  it  formed  from  without  inward  of  a  cutaneous 
layer,  presenting,  at  most,  but  a  slight  down  ;  of  a  dense  layer  of  a 
slightly  adipose  cellular  tissue,  in  which  are  some  fibres  of  the  platysma 
and  the  superficial  nerves ;  of  a  deeper  layer,  formed  by  a  chain  of 
lymphatic  ganglions  situated  before  the  auditory  passage  and  on  the 
outer  face  of  the  parotid  gland  which  is  loose  anteriorly^  and  forms  a 
plane,  at  the  circumference  of  which  are  detached  ;  above,  the  tem- 
poral vessels  and  nerves,  either  the  branch  of  the  inferior  maxillary  or 
those  of  the  facial ;  posteriorly,  on  the  anterior  edge  of  the  mastoid 
process,  the  posterior  auricular  artery,  and  the  auricular  twigs  of  the 
facial  nerve,  and  of  the  superficial  cervical  plexus.  If  we  proceed 
forward  two  lines  from  the  gland,  we  come  to  the  filaments  of  the 
facial  nerve  ;  if  we  dissect  off  four  in  the  centre  and  six  posteriorly  we 
come  to  the  trunk,  Directly  below  this  plane,  which  is  oblique  for- 
ward and  outward,  and  is  formed  by  the  radiation  of  the  facial  nerve, 
we  find  the  temporo-parotid  vein,  which  is  the  principal  origin  of  the 
external  jugular  vein ;  below  comes  also  a  segment  of  the  gland,-  then 
the  external  carotid  artery,  which  is  sometimes  situated  directly  on  the 
styloid  process,  and  sometimes  in  a  groove  of  the  inner  face  of  the 
parotid  gland. 

This  region  is  bounded  on  the  inside  and  downward  by  the  carotid 
region,  which  we  shall  study  hereafter  ;  posterior^  by  the  auditory 
passage  and  the  mastoid  region ;  anteriorly,  by  the  malar  region,  and 
superiorly  by  the  temple. 

Varieties.  In  children  the  parotid  region  is  broad  at  the  lower  part, 
because  the  ramus  of  the  jaw  is  oblique  anteriorly  ;  it  is  convex  on  the 
outside  on  account  of  the  external  fat,  and  because  the  lymphatic 
ganglions  are  very  much  developed ;  in  the  adult,  the  dimensions  of 
the  maxillary  bone,  which  becomes  straighter,  have  served  us  as  a 
type  ;  in  the  old  man,  the  region  enlarges  at  the  lower  part,  and  again 
assumes  the  characters  of  infancy. 

Sometimes  the  external  carotid  artery  does  not  exist ;  the  primitive 
carotid  artery  does  not  divide  until  below  the1  cranium. 

Pathological  and  operative  deductions.    In  deep  wounds  of  this 

16 


122  TOPOGRAPHICAL    ANATOMY. 

region,  the  external  carotid  artery  may  be  injured  :  in  these  cases,  it 
may  be  very  difficult  to  tie  the  artery  in  the  wounded  part,  on  account 
of  the  narrowness  of  the  space  ;  it  must  then  be  exposed  below  the 
region,  or  the  primitive '  carotid  artery  must  be  tied,  as  was  done  by 
Marjolin.  These  wounds  are  often  followed  with  very  obstinate 
fistulee,  caused  by  the  injury  of  the  radicles  of  the  duct  of  Steno. 
When  the  jaw  is  broken,  the  fragments  may  be  directed  toward  the 
parotid  gland,  and  cause  in.it  an  inflammation,  followed  by  a  greater 
or  less  external  swelling.  This  inflammation  may  affect  several  of  the 
elements  of  this  glan  dfirst,  its  granulations  ;  second,  its  interlobular 
cellular  tissue,  as  in  most  swellings  of  the  gland  in  adynamic  fevers  ; 
third,  finally,  its  numerous  veins.  This  .last  character  is  sometimes, 
presented  in  severe  fevers,  as  we  have  observed :  we  believe,  also,  that 
this  kind  of  tumor  has  been  overlooked,  because  it  was  thought  that 
the.  pus  which  came  from  the  divided  orifices  of  the  veins  escaped  from 
small  abscesses  in  the  cellular  tissue.  Farther,  these  abscesses  may 
point  in  the  auditory  passage  after  destroying  the  tissue  which  fills  the 
grooves  of  Santorini ;  they  may  proceed  inward,  toward  the  internal 
carotid  vessels  which  they  compress  ;  but  most  frequently,  they  point 
externally.  The  parotid  gland  may  swell,  in  consequence  of  the  saliva 
continuing  in  its  excretory  passages  naturally,  or  by  an  obstruction  to 
its  circulation  in  the  principal  duct :  schirrous  tumors  of  this  region 
may  also  be  based  upon  this  gland  ;  but  we  must  admit  that  most  of 
•them  are  situated  in  the  ganglions  which  cover  it.  This  position  also 
explains  admirably  what  occurs  in  this  case  ;  the  gland  is  crowded 
inward  and  wasted  :  this  circumstance  has  often  led  to  the  belief  that 
in  extirpating  tumors  from  this  part,  the  parotid  gland  has  been  re- 
moved, because  a  considerable  depression  existed  after  the  operation : 
this  extirpation  was  seldom  performed  before  the  time  of  Beclard,*  who 
certainly  removed  it,  and  opened  the  external  carotid  artery  during 
the  operation,  and  this  is  situated  on  the  internal  limit  of  the  gland. 
Farther,  the  anatomy  of  this  region  shows  the  danger  of  this  attempt: 
all  the  deep  nerves  of  the  region  are  inevitably  destroyed,  particularly 
the  facial  nerve,  which  is  extremely  important  to  the  cheek,  the  neck, 
and  the  temple  :  after  the  operation,  the  lips  and  the  al*  of  the  nose 
remain  paralyzed  during  the  motions  of  respiration.  All  the  vessels, 
and  even  the  carotid  artery,  are  necessarily  divided.  To  prevent  the 
bad  symptoms  which  might  result  from  dividing  the  carotid  artery, 
Beclard  recommended  to  tie  it  below,  before  removing  a  portion  of  the 
gland  which  contains  it.  This  course  should  be  adopted :  we  thus 
*.  . 

*  The  parotid  gland  was  first  extirpated  by  Prof.  Samuel  White,  of  Hudson,  New  York, 
in  1808. 


LARYNGO-TRACHEAL  REGION.  123 

avoid  a  severe  hemorrhage,  and  we  gain  time  to  tie  the  other  arteries, 
particularly  the  internal  maxillary,  which  passes  under  the  neck  of  the 
condyle  of  the  jaw :  hemorrhage  would  certainly  ensue  from  this 
artery,  which  is  supplied  with  blood  by  the  anastomoses  of  its  branches. 
In  cases  of  facial  neuralgia,  the  division,  or  rather  the  removal  of  a 
portion  of  the 'facial  nerve,  has  been  performed  since  the  time  .of 
Mareschal,  particularly  by  Roux,  but  generally  without  success :  per- 
haps this  failure,  may  be  ascribed  to  the  performance  of  the  operation 
at  the  anterior  part,  or  at  the  centre  of  the  region,  in  points  where  the 
nerve  is  separated,  and  its  filaments  are  very  remote  from  each  other. 
To  obviate  this,  Beclard  recommended  to  operate  on  the  trunk  of  the 
nerve,  where  it  emerges  from  the  stylo-mastoid  foramen  ;  a  difficult 
operation ;  but  it  may  be  performed  by  making  an  incision  parallel  to 
and  near  the  mastoid  process,  and  by  separating  the  parotid  gland 
which  is  attached  to  it :  then  at  the  depth  of  half  an  inch  we  find  the 
nerve,   which   crosses  the  wound  obliquely :  we  inevitably  cut  the 
posterior  auricular  artery.     In  the  adult,  the  carotid  artery  may  be 
compressed  at  the  base  of  the  region,  on  the  stylpid  process. 


ORDER       SECOND. 

.'    •     • 

NATURAL    REGIONS    OF    THE    INFRA-HfOID    PART   OF    THE    NECK. 

This  order,  like  the  preceding,  includes  two  regions :  the  infra-hyoid 
or  the  laryngo-tracheal,  and  the  supra-clavicular. 


1.       LARYNGO-TRACHEAL       REGION. 

This  region'  is  unmated,  symmetrical,  situated  on  the  median  line, 
and  forms  this  part  of  the  neck  included  inferiorly  between  the  hyoid 
bone  and  the  sternum,  which  form  its  superior  and  inferior  boundaries  : 
it  is  situated  between  the  two'sterno-mastoidei  muscles,  and  is  bounded 
by  their  anterior  edges,  which  become  very  prominent  when  the  head 
is  raised  and  the  face  is  thrown  forward. 

This  region  is  convex  above,  and  depressed  below,  and  presents  a 
series  of  prominences  and  depressions,  which  are  situated  from  above 
downward :  that  of  the  body  of  the  hyoid. bone,  the  thyro-hyoid  space 
which  is  terminated  below  by  an  edge  grooved  in  the  centre,  the 
angular  thyroid  prominence,  the  .crico-thyroid  space,  the  variable 
prominence  of  the  thyroid  body,  and  the  supra-sternal  fossa,  which  is 
very  distinct  in  inspiration :  finally,  upwar.d  and  outward,  a  depression 


124  TOPOGRAPHICAL  ANATOMY. 

to  which  we  shall  recur  when  speaking  of  the  carotid  region,  although 
it  is  included  in  the  lateral  boundaries  which  we  have  laid  down :  at 
the  base  of  this  depression  we  can  perceive,  on  the  slightest  pressure, 
the  strong  pulsations  of  the  carotid  artery. 

Structure. — 1.  Elements.  This  region  rests  wholly  upon  the 
anterior  part  of  the  spine,  which  does  not  properly  belong  to  it,  but 
which  serves  as  deep  limits  for  it,  as  does  also  the  longus  colli  muscle, 
which  rests  directly  upon  it.  It  is  composed  of  the  upper  part  of  the 
trachea  and  of  its  expansion,  the  larynx,  of  the  thyroid  gland,  of  a 
portion  of  the  pharynx,  and  of  the  esophagus,  the  latter  inclining  to 
the  left.  These  complex  organs,  particularly  the  pharynx,  which  are 
formed  of  membranous  muscles,  &c.,  need  not  be  described  here  :  we  - 
refer  for  them  to  works  on  descriptive  anatomy,  to  which  they  belong, 
and  in  which  they  are  described  as  small  regions.  We  also  find  in 
the  laryngo-tracheal  region,  all  the  infra-hyoid,  the  sterno-hyoid  and 
thyroid,  the  thyro-hyoid,  and  the  scapulorhyoid  muscles,  and  a  small 
portion  of  the  platysma-myoid  muscle  :  the  cervical  aponeurosis,  which 
is  formed  in  this  part  of  three  layers,  as  we  have  seen,  when  treating 
generally  of  the  tracheal  portion  of  the  neck  :  two  of  them  embrace 
the  sternum,  and  are  continuous  ;  one,  superficially  with  the  sub- 
cutaneous tissue  of  the  thorax ;  the  other,  deeply  with  the  posterior 
periosteum  of  the  sternum :  the  middle,  on  the  contrary,  is  inserted  in 
the  upper  part  of  this  bone,  which  is  thus  extended  to  the  neck,  if  we 
may  be  allowed  the  expression.  We  also  number,  first,  the  four  thyroid 
arteries  in  the  normal  state,  of  which  the  two  upper  come  from  the 
external  carotid  artery,  and  give  off  the  superior  laryngoaal  arteries  ; 
while  the  two  inferior  ascend  from  the  subclavian  artery,  and  give  off 
the  small  crico-thyroid  arteries,  which  pass  through  the  crico-thyroid 
membrane  :  second,  the  brachio-cephalic  trunk,  which  proceeds  ob- 
liquely downwards  from  left  to  right.  The  veins  are  deep,  or  super- 
ficial :  the  deep  go  to  the  thyroid  gland,  which  is  very  vascular  ;  the 
superior  follow  the  course  of  the  superior  artery,  and  go  toward  the 
internal  jugular  vein :  the  central  proceed  from  the  side  to  the  same 
destination :  finally,  the  sub-thyroid  descend,  and  anastomose  in  a 
plexus,  around  the  left  subclavian  vein,  which  crosses  below,  in  an 
opposite  direction  to  the  innominata  artery.  Of  the  superficial  veins,  the 
most  constant  are  the  two  anterior  jugular,  which  follow  the  anterior 
edge  of  the  sterno-mastoid  muscles  to  the  lower  part,  curve  under  them 
at  a  right  angle>  and  terminate  in  the  external  jugular  vein :  these 
veins,  which  are  often  very  large  antf  anastomose  on  the  median  line 
by  transverse  branches,  descend  from  the  supra-hyoid  region,  and 
most  frequently  communicate,  under  the  angle  of  the  jaw,  with  the 
internal  jugular  vein,  sometimes  with  the  external  or  the  superior 


LARYNGO-TRACHEAL   REGION.  •         125 

thyroid  vein :  finally,  we  sometimes  find  on  the  median  line  another 
vein,  which  comes  from  the  supra-hyoid  region,  like  the  preceding, 
and  terminates  in  this,  or  in  one  of  the  sub-thyroid  veins.  One  or  two 
lymphatic  ganglions  are  situated  in  the  supra-sternal  space :  they 
receive  some  lymphatic  vessels  of  this  region,  and  some  also  of  the 
sternal  region;  but  most  of  the  lymphatic  vessels  of  the  laryngo- 
tracheal  region  go  to  the  lateral  ganglions  of  the  neck.  We  also  find 
there  some  superficial  nerves,  filaments  of  the  cervical  plexus ;  some 
central  nerves  from  the  nervous  plexus  of  the  great  hypo-glossal  nerve, 
and  from  the  internal  descending  twig  of  the  cervical  plexus ;  some 
deep  nerves,  the  recurrent,  the  superior  laryngceal,*  and  some  filaments 
of  the  tri-splanchnic  nerve ;  some  cellular  tissue,  very  loose  even  on 
the  median  line,  an  arrangement  which  is  necessary  for  the  motions 
of  the  principal  organ  of  this  region,  the  trachea ;  a  small  quantity  of 
adipose  tissue  :  finally,  on  the  upper  and  outer  part  of  the  larynx,  we 
also  find  on  the  inside  of  this  region  a  portion  of  the  primitive  carotid 
artery,  of  the  internal  jugular  vein,  the  par  vagum,  and  the  great 
sympathetic  nerve,  and  some  lymphatic  ganglions,  to  which  we  shall 
attend  hereafter. 

2.  Relations.  The  first  layer  of  this  region  is  formed  by  the  skin  ; 
the  last  by  the  spine,  before  which  the  longus  colli  muscles  are  situated  : 
between  these  two  extreme  parts  we  find  successively ;  from  without 
inward,  a  sub-cutaneous  cellular  tissue,  very  loose  even  on  the  median 
line  ;  the  superficial  fold  of  the  cervical  aponeurosis  inferiorly,  supe- 


*  We  have  attended  particularly  to  the  nerves  of  the  larynx :  the  following  are  our  results. 
The  superior  laryngoeal  nerve  is  distributed  particularly  to  the  mucous  membrane  and  the 
crypts  of  the  larynx :  it  also  sends  off,  as  Magendie  has  shown,  a  filament  into  the  erico- 
thyroideus  muscle,  and  some  others  which  are  less  constant,  into  the  arytenoideus  muscle. 
The  recurrent  nerve  is  distributed  to  the  two  muscles  which  dilate  the  glottis,  to  the  aryteno- 
thyroideus  muscle,  and  finally  to  the  arytenoideus  muscle,  by  a  large  filament,  which  passes 
behind  the  crico-arytenoid  articulation,  under  the  posterior  crico-arytenoideus  muscle.  Thus, 
the  recurrent  nerve  properly  belongs  to  all  the  muscles  which  dilate  or  contract  the  larynx, 
except  the  crico-thyroideus,  which  acts  but  slightly  on  the  glottis.  The  superior  laryngceal 
nerve  belongs  almost  entirely  to  the  mucous  membrane,  and  by  some  filaments  to  the  aryte- 
noideus muscle. 

We  have  said  that  the  crico-thyroideus  muscle  acts  but  slightly  on  the  glottis.  As  this 
opinion  differs  from  that  of  physiologists  generally,  we  must  defend  it.  This  muscle,  they 
sav,  causes  the  cricoid  cartilage  to  vibrate  on  the  thyroid,  or  the  second  on  the  first,  which  it 
is  unimportant ;  this  draws  one  of  the  angles  of  the  glottis,  tenses  its  lips,  brings  them 
together,  and  acts  as  the  hand  upon  a  button-hole,  the  angles  of  which  it  draws  up.  The 
conclusion  is  not  correct.  The  crico-arytenoideus  muscle  certainly  tenses  the  lips  of  the 
glottis,  but  nothing  more.  In  fact,  in  order  that  the  opening  of  the  larynx  may  be  closed  like 
a  button-hole,  it  should  also  be  opened  in  the  same  manner  under  the  influence  of  a  force 
which  produces  the  curve  of  its  two  lips  ;  but  experience  demonstrates  that  this  does  not 
occur :  in  the  motion  of  dilatation,  the  arytenoid  extremity  of  one  of  the  lips  of  the  glottis  is 
simply  removed  from  the  other. 


126  TOPOGRAPHICAL    ANATOMY. 

riorly  the  entire  aponeurosis,  and  the  two  platysma  muscles;  more 
deeply,  and  at  the  base  only,  a  triangular  space,  which  is  bounded 
posteriorly  by  the  very  dense  central  layer  of  the  cervical  aponeurosis : 
this  space  readily  communicates,  under  the  sterno-mastoideus  muscle, 
with  the  supra-clavicular  region  ;  and  we  find  in  it  on  each  side,  near 
the  sterno-mastoideus  muscle,  first,  the  anterior  jugular  vein,  on  th,e 
median  line ;  second,  frequently  a  vein,  which  descends  from  the 
supra-hyoid  region  towards  the  thyroid  plexus  ;  third,  some  lymphatic 
ganglions ;  fourth,  below,  some  venous  twigs,  which  come  from  the . 
sternal  region,  and  open  into  the  anterior  jugular  vein.  .Below  the 
cervical .  aponeurosis,  which  is  single  above,  and  the  two  inferior 
layers,  which  have  already  been  mentioned,  appears  a  first  fleshy 
layer,  formed  by  the  sterno-hyoid  muscle,  and  the  anterior  belly  of  the 
scapulo-hyoid  muscles ;  a  second  plane,  which  is  also  fleshy,  and 
formed  by  the  two  thyro-hyoid  and  the  sterno-hyoid  muscles,  the  latter 
.covered,  by  the  nervous  filaments  of  the  plexus  of  the  great  hypo-glossal 
nerve.  All  these  muscles  being  removed,  we  see  nearly  all  the  anterior 
face  of  the  larynx,  the  thyroid  gland  concealing  the  larynx  very 
slightly,  and  giving  origin,  by  its  lower  edge,  to  the  deep  layer  of  the 
cervical  aponeurosis  (which  layer  covers  the  sub-thyroid  venous  plexus,) 
and  very  near  the  sternum,  the  left  subclavian  vein  and  the  brachio- 
cephalic  trunk,  which  cross  and  go  upward  ;  the  first  is  superficial,  is 
directed  obliquely  to  the  left ;  the  second  is  deep,  and  proceeds  obliquely 
to  the  right ;  they  thus  form  between  them  an  angle,  the  sinus  of  which 
is  turned  upward,  and  embraces  the  trachea.  Below  the  thyroid 
gland,  which  proceeds  on  the  outside  into  the  carotid  region,  and  below 
the  sub-thyroid-  venous  plexus,  we  find  the  trachea,  which  is  situated 
more  deeply  than  the  larynx.  If.  we  now  analyze  this  layer  more 
minutely,  in  the  part  where  it  is  formed  by  the  larynx,  we. find,  first, 
the  thyro-hyoid  membrane,  on  the  outside  of  which  the  superior 
laryngosal  vessels  and  nerves  pass  ;  a  membrane,  corresponding  on  the 
inside  to  the  anterior  face  of  the  epiglottis,  and  to  the  upper  opening 
of  the  larynx ;  second,  the  thyroid  angle,  which  corresponds  to  the 
cavity  of  the  larynx,  serves  on  the  inside  for  the  insertion  of  the  vocal 
cords,  and  bounds  the  ventricles  of  .the  larynx  anteriorly;  third,  the 
lateral  layers  of  the  thyroid  cartilage,  sometimes  presenting  a  rounded 
opening,  closed  by  some'  cellular  tissue  :  on  these  layers,  the  external 
laryngoeal  nerve,  the  superior  thyroid  artery,  and  the  origin  of  the 
inferior  constrictor  of  the  pharynx,  pass  outwardly ;  and  finally,  these 
layers  correspond  internally  upward  and  backward  to  the  pharynx, 
downward  and  forward  to  a  mucous  sinus  of  the  same  cavity,  to  the 
lateral  crico-arytenoid  and  crico-thyroid  muscles ;  fourth,  finally,  the 
crico-thyroid  space,  which  is  formed  laterally  by  the  muscles,  and  in 


LARYNGO-TRACHEAL  REGION.  127 

the  centre  by  the  crico-thyroid  membrane,  on  which  the  small  crico- 
thyroid  artery  glides  forward,  while  its  numerous  twigs  pass  through 
the  foramina  of  this  membrane :  this  space  corresponds  in  the  larynx 
to  below  the  level  of  the  glottis.  Behind  the  larynx  comes  the  pharynx, 
the  anterior  wall  of  which  is  formed  in  one  point  by  the  former  ;  arid 
behind  the  trachea,  the  posterior  part  of  which  is  membranous,  we 
find ;  on  the  right,  the  right  recurrent  nerve ;  on  the  left,  the  esophagus, 
which  comes  to  this  .side,  and  presents  upon  its  anterior  face  the  cor- 
responding recurrent  nerve,  and  the  inferior  thyroid  artery  :  still  more 
deeply,  a  very  loose  cellular  tissue,  which  covers  the  longus  colli 
muscles  and  the  spine. 

Development.  This  region  assumes  at  puberty  its  characteristic 
size.  Until  this  period  we  find  under  the  deep  layer  of  the  cervical 
aponeurosis,  in  front  of  the  trachea,  a  small  part  of  the  thymus  gland, 
which  even  ascends  to  the  thyroid  gland  before  the  sixth  month  of 
pregnancy. 

'Uses.  The  use  of  the  three  aponeurotic  layers,  which  are  placed  in 
.this  part,  is  to  protect  the  trachea,  and  to  prevent  its  compression  in 
inspiration,  when  the  external  air  tends  in  every  part  to  enter  the 
lungs. 

Varieties.  This  region  presents  very  important  varieties ;  some* 
times  a  middle  thyroid  artery  ascends  in  front  of  the  trachea,  coming 
from  the  innominata  or  from  the  arch  of  the  aorta ;  we  have  seen  it 
as  large  as  the  radial  artery ;  the  isthmus  or  one  of  the  lobes  of  the 
thyroid  gland  sometimes  extends  to  the  hyoid  bone,  by  one  or  two  slips 
formed  from  it,  or  by  a  pair  of  small  muscles  which  we  have  some- 
times seen.  Sometimes  the  superior  thyroid  artery  sends  on  the  crico-  . 
thyroid  membrane  one  of  its  largest  branches,  which  gives  off  some 
small  twigs  to  the  larynx,  and  then  curves  toward  the  thyroid  body, 
its  destination.  We  have  known  the  superior  thyroid  and  also  the  in- 
ferior thyroid  artery  to  be  deficient,  or  to  be  replaced  by  a  very  small 
twig;  we  have  known  it  to  come  from  the  carotid  artery  at  the 
thyroid  gland  ;  and  very  recently  also,  we  have  seen  it  arising,  as 
usual,  from  the  subclavian  artery,  but  passing  on  the  outside  of  the. 
primitive  carotid,  and  coming  superficially  into  the  thyroid  gland. 
The  left  carotid  artery  may  come  from  the  brachio-cepha-lic  trunk,  and  • 
pass  before  the  trachea  ;  the  right  subclavian  artery,  instead  of  being 
formed  by  the  brachio-cephalic  trunk,  may  be  the  last  trunk  from  the 
arch  of  the  aorta,  or  arise  between  the  other  trunks  ;  it  then  always 
passes  between  the  trachea  and  the  esophagus  ;  we  have  seen  an  in- 
stance of  this. 

This  region  presents  a. deeper  cavity  in  the  male  than  in  the  female. 


128  TOPOGRAPHICAL  ANATOMY. 

It  is  longest  when  the  neck  is  extended ;  hence  this  position  is  required 
in  operating  upon  it. 

Pathological  and  operative  deductions.  Wounds  of  this  region 
are  common  ;  it  is  difficult,  on  account  of  the  mobility  of  the  deep 
organs,  for  their  external  opening  to  remain  parallel  to  that  of  the 
trachea  when  this  has  been  wounded  ;  hence  arise  infiltrations  of  air, 
and  if  a  vessel  has  been  divided  the  blood  flows  into  the  trachea. 
Suicides  often  select  the  thyro-hyoid  space  for  their  purpose,  which 
they  doubtless  consider,  on  account  of  its  feebleness,  as  best  adapted  for 
the  purpose  of  self-murder  ;  the  wounds  are  rarely  deep  enough  to 
produce  a  hemorrhage,  because  these  unfortunate  persons  stop  as  soon 
as  they  have  penetrated  into  the  throat  and  the  air  issues  forth.  Never- 
theless the  epiglottis,  which  is  then  divided,  may  by  its  depression  on 
the  larynx  cause  severe  symptoms.  If,  as  we  have  seen,  the  wounding 
instrument  has  acted  lower  on  the  thyroid  cartilage,  the  vocal  cords 
may  have  been  affected,  and  the  voice  changed.  Wounds  in  the 
crico-thyroid  membrane  and  below  it,  besides  being  attended  with 
emphysema  and  hemorrhage,  may  be  followed  by  fistulae,  which  are 
rendered  serious  by  their  position  below  the  glottis  ;  they  prevent  the 
formation  of  sounds,  except  when  they  are  closed.  A  pointed  instru- 
ment introduced  obliquely  downward  into  the  supra-sternal  hollow,  as 
is  done  in  order  to  bleed  those  animals  used  for  meat,  would  wound 
the  brachio-cephalic  trunk  and  the  left  subclavian  vein  at  the  place 
where  these  vessels  cross ;  finally,  the  wounding  body,  on  deviating  to  the 
side,  might  wound  the  carotid  vessels  which  are  situated  near  the  la- 
ryngo-tracheal  region.  Foreign  bodies  may  exist  in  the  air-passages ; 
sometimes  they  form  in  this  part,  or  they  come  into  it  from  without,  or 
from  the  esophagus  and  the  stomach,  as  intestinal  worms,  for  in- 
stance. Whatever  may  be  the  origin  of  these  foreign  bodies,  they  are 
generally  introduced  into  the  trachea  by  a  motion  opposite  to  deglu- 
tition, as  we  have  seen  ;  they  irritate  the  mucous  membrane,  cause  a 
convulsive  cough,  during  the  fits  of  which,  many  pulmonary  cells  are 
sometimes  ruptured,  and  as  authors  have  observed,  emphysema  of  the 
infra-hyoid  region  may  occur.  In  order  to  extract  these  bodies  the 
air-passages  are  opened ;  this  operation  was  termed  by  the  ancients 
bronchotomy ;  this  comprises  three  species  ;  laryngotomy,  tracheo- 
tomy, and  laryngo-tracheotomy ;  all  of  them  with  some  modifications 
are  indicated,  where  a  mechanical  obstacle  opposes  the  introduction  of 
air  into  the  lungs  ;  whether  this  is  prevented  by  a  foreign  body  lodged 
in  the  esophagus,  or  the  larynx  is  obstructed  by  an  inflammation,  &c. 

When  we  wish  simply  to  cut  the  crico-thyroid  membrane,  we  divide 
before  coming  to  it,  the  skin  and  the  cervical  aponeurosis,  which  is 
single  in  this  point,  and  we  separate  the  sterno-hyoid  and  thyroid  mus- 


LARYNGO-TRACHEAL  REGION.  129 

cles.  We  always  divide  the  crico-thyroid  arterial  branches  and  the 
superficial  median  vein  when  it  exists.  All  these  vessels  should  be 
tied  before  the  membrane  is  divided.*  This  may  be  punctured  with  a 
trocar ;  we  even  think,  that  with  proper  precautions,  which  we  shall 
mention  hereafter,  this  is  the  best  mode  of  operating;  if  we  desire  a 
larger  •  opening  in  the  larynx,  we  divide  the  thyroid  cartilage,  as 
Boyer  recommends  ;  it  must  be  cut  on  the  median  line,  lest  the  vocal 
cords  be  injured  ;  if  we  wish  to  carry  the  incision  downward  on  the 
cricoid  cartilage  and  the  upper  rings  of  the  trachea,  we  necessarily 
divide  the  isthmus  of  the  thyroid  gland  and  its  vessels,  which  are  often 
very  large,  although  some  authors  assert  the  contrary ;  hence  a 
hemorrhage  which  is  always  injurious  and  may  be  fatal. 

To  operate  with  safety,  we  must  vary  from  the  course  usually  pre- 
scribed ;  instead  of  dividing  the  trachea  and  the  thyroid  gland  from 
within  outward,  we  must  commence  with  the  latter,  tie  its  vessels,  and 
afterwards  open  the  trachea.  If  the  blood  falls  into  the  trachea,  and 
the  patient  is  in  danger  of  suffocation,  we  must  imitate  the  course  of 
Roux,  who  almost  restored  a  patient  to  life  by  sucking  out  the  blood 
which  prevented  the  access  of  the  air.  The  operation  of  tracheotomy 
is  still  more  serious ;  the  trachea  is  situated  more  deeply >  and  also  it  is 
covered  with  the  sub-thyroid  venous  net-work,  through  the  interstices 
of  which  it  must  be  divided ;  in  order  to  this  we  must  cut  suc- 
cessively ;  the  skin,  the  two  superficial  layers  of  the  cervical  aponeu- 
rosiS)  separate  the  sterno-hyoid  and  thyroid  muscles,  divide  the  last 
layer  of  the  preceding  aponeurosis,  and  glide  the  instrument  between 
the  sub-hyoid  venous  branches  ;  the  position  of  the  ihnominata  artery 
and  of  the  subclavian  vein,  indicates  that  the  trachea  must  not  be  di- 
vided too  low,  in  order  to  avoid  injuring  them ;  Beclard  stated  that 
this  accident  happened  to  a  medical  student  who  performed  the  ope- 
ration of  tracheotomy  to  restore  his  drowned  friend.t  When  the 
superior  thyroid  artery  comes  on  the  crico  thyroid  membrane,  or  when 
an  inferior  middle  thyroid  artery  exists,  these  vessels  must  be  tied 
before  the  trachea  is  opened  ;  to  perceive  them  the  finger  must  always 
be  carried  to  the  bottom  of  the  wound. 

When  a  foreign  body  is  arrested  in  the  cervical  portion  of  the  eso- 
phagus, it  compresses  the  trachea  situated  before  it,  and  flattens  it,  and 

*  By  following  this  direction,  we  performed  this  operation  the  last  year,  and  not  a  drop  of 
blood  escaped  into  the  larynx  when  the  crico-thyroid  membrane  was  divided.  The  patient 
was  saved  from  instant  suffocation,  but  died  three  days  after,  as  the  inflammation  of  the 
larynx  had  made  great  progress. 

|  Detharding  proposes  to  perform  this  operation  to  restore  drowned  persons,  who,  in  his 
opinion,  are  suffocated  by  the  depression  of  the  epiglottis  on  the  larynx.  The  experiments  of 
Louis  have  justified  this  opinion. 


130  TOPOGRAPHICAL    ANATOMY. 

this  more  easily,  because  the  trachea  on  this  side  is  membranous ; 
hence  also  the  respiration  is  more  or  less  obstructed.  If  this  body 
cannot  be  extracted  or  pushed  into  the  stomach,  it  must  be  removed 
by  esophagotomy  ;  this  operation  should  be  performed  on  the  left  side, 
on  account  of  the  deviation  of  the  esophagus ;  the  vessels  and  nerves 
in  the  carotid  region  must  not  be  wounded,  the  tumor  in  its  develop- 
ment presses  them  outward  and  backward  ;  the  inferior  thyroid  artery, 
however,  will  be  endangered  if,  as  we  have  said,  it  should  pass  on  the 
outside  of  the  carotid  artery,  or  if  we  forget  that  it  always  glides  in 
front  of  the  origin  of  the  esophagus.  The  left  recurrent  nerve  will  be 
avoided  by  cutting  the  esophagus  laterally,  the  nerve  being  situated 
forward.  Superficial  abscesses  of  this  region  may  be  left  to  them- 
selves j  they  seldom  point  toward  the  mediastinum  which  is  protected 
on  this  side  by  three  layers  of  the  cervical  aponeurosis  ;  the  middle 
abscesses  have  not,  however,  this  arrangement,  on  account  of  the 
weakness  of  the  superficial  fold  of  this  aponeurosis ;  but  they  readily 
proceed  into  the  supra-clavicular  region,  passing  under  the  sterno- 
mastoideus  muscle,  gliding  on  the  deep  layer  of  the  fascia  and  accom- 
panying the  last  portion  of  the  external  and  anterior  jugular  vein  ;  to 
avoid  this  termination  they  must  be  opened  early.  The  deep  abscesses 
often  proceed  toward  the  mediastinum,  before  they  can  be  perceived 
externally.  The  same  remarks  apply  to  tumors  of  a  different  cha- 
racter from  abscesses  ;  it  is  evidently  on  account  of  the  resistance  pre- 
sented by  the  cervical  aponeurosis  to  their  external  development,  that 
the  deep  tumors  compress  the  trachea  and  impede  respiration ;  this  is 
seen  in  goitre ;  the  thyroid  gland,  when  thus  affected,  has  been  suc- 
cessfully removed,  but  the  extirpation  of  the  whole  organ  has  often 
been  fatal ;  in  fact,  this  operation  cannot  be  performed  without  expo- 
sing a  number  of  important  parts,  and  especially  without  giving  rise 
to  an  enormous  wound,  and  extreme  care  and  great  skill  are  necessary 
to  avoid  a  fatal  hemorrhage.  Serous  cysts  of  the  thyroid  gland, 
which  Maunoir  has  removed  by  irritating  injections,  and  which  he 
terms  hydrocde  of  the  neck,  present  nothing  peculiar.  We  shall  not 
mention  the  ligature  of  the  thyroid  arteries  proposed  to  cure  goitre, 
by  causing  it  to  waste ;  this  operation  is  not  admitted. 


SUPRA-CLAVICULAR    REGION.  131 


2.       S  U  P  R  A-C  LAVICULAR       REGION. 

This  region  forms  the  lateral  and  inferior  part  of  the  tracheal  portion 
of  the  neck :  it  is  situated  directly  above  the  clavicle,  which  forms  its 
lower  boundary,  between  the  sterno-mastoideus  on  one  side,  arid  the 
trapezius  and  the  splenius  on  the  other,  which  bound  it  anteriorly  and 
posteriorly.  It  has  the  form  of  a  triangle,  the  base  of  which  is  situated 
at  the  lower  part :  its  extent  is  always  proportional  to  that  of  the 
clavicle,  and  may  readily  be  estimated  externally.  Its  limits  are  easily 
seen  :  they  are  those  of  the  supra-clavicular  depression,  so  marked  in 
old  men  and  thin  persons,  during  the  elevation  of  the  shoulder. 
Farther,  the  outer  surface  of  this  portion  of  the  neck  is  destitute  of 
hairs  ;  the  skin  plays  upon  it  easily  ;  and  the  finger,  if  passed  down- 
ward and  inward,  perceives  in  it  very  strong  arterial  pulsations. 

Structure.  —  L  Elements.  This  region  rests  on  the  anterior  and 
lateral  part  of  the  spine,  which  bounds  it  on  the  inside ;  below,  the 
clavicle  and  the  first  rib  are  seen :  this  latter  presents  above,  for  the 
axillary  artery,  a  depression,  which  is  bounded  anteriorly  by  a  promi- 
nence, where  the  scalenus  anticus  muscle  is  inserted,  and  the  face  of 
this  bone  looks  upward,  and  slightly  outward.  Several  muscles  are 
partially  situated  in  this  region,  but  most  of  them  pass  through  it,  or 
terminate  there.  We  see,  also,  the  last  cervical  inter-transverse 
muscles ;  two,  and  sometimes  three  scaleni  form  there  a  triangular 
space,  the  base  of  which  looks  to  the  first  rib.  The  scapulo-hyoideus 
muscle  passes  through  the  region,  in  a  line  drawn  from  the  centre  of 
the  clavicle  to  the  hyoid  bone :  before  this  last  point,  it  is  parallel  to 
the  clavicle,  to  which  it  is  attached  by  a  prolongation  of  the  cervical 
aponeurosis  :  we  find  there,  also,  a  very  small  portion  of  the  platysma 
muscle.  The  sterno-mastoideus,  trapezius,  splenius,  and  levator  anguli 
scapulae  muscles,  which  are  situated  on  the  limits  of  the  supra-clavicular 
space,  must  not  be  considered  in  this  place.  The  cervical  aponeurosis 
sends  into  this  region  its  deep  layer,  which,  after  passing  under  the 
sterno-mastoideus  muscle,  terminates  on  the  scapulo-hyoideus  muscle, 
and  the  posterior  edge  of  the  clavicle.  The  superficial  layer  of  the 
cervical  aponeurosis  is  here  deficient,  and  is  replaced  by  the  platysma. 
Numerous  and  very  important  arteries  pass  through  this  region,  and 
send  to  it  some  branches.  In  the  first  rank,  we  must  place  the  trunk 
which  goes  to  the  arm.  It  describes  in  this  place  a  curve,  convex 
superiorly,  the  concavity  of  which  embraces  the  cul-de-sac  formed  by 
the  passage  of  the  pleura  near  the  first  rib.  This  large  artery  is 
termed  the  axillary,  when  it  leaves  the  space  between  the  scaleni 


132  TOPOGRAPHICAL  ANATOMY. 

muscles,  and  in  this  space,  the  subclavian.  In  the  second  rank,  we 
must  mention  the  branches  which  come  off  from  the  subclavian  artery : 
some  proceed  horizontally,  from  behind  forward,  viz. :  first,  the  trans- 
verse cervical,  two  fingers'  breadth  from  the  clavicle ;  second,  the 
superior  scapular,  which  normally  arises  along  the  posterior  edge  of 
the  clavicle  situated  between  the  two  layers  of  the  cervical  aponeurosis  ; 
third,  the  deep  cervical  artery,  between  the  transverse  processes  of  the 
sixth  and  seventh  cervical  vertebrae ;  all  go  to  the  posterior  cervical 
or  scapular  region ;  others  ascend  perpendicularly :  they  are  the  ver-  • 
tebral,  which  is  concealed  by  the  scalenus  anticus  muscle ;  the  ascending 
cervical  artery,  a  branch  of  the  inferior  thyroid.  All  these  arteries  are 
accompanied  by  veins,  which  present  almost  the  same  arrangement, 
except  the  axillary  vein,  which  does  not  pass  into  the  space  between 
the  scaleni,  but  glides  along  in  front  of  it.  The  external  jugular  vein 
terminates  in  the  axillary  trunk,  in  the  anterior  part  of  the  supra- 
clavicular  region,  after  receiving  the  supra-scapular  veins,  We  find 
in  this  part  numerous  lymphatic  ganglions,  some  of  which  are  super- 
ficial, and  others  deep :  they  are  continuous  with  those  of  the  axilla, 
with  the  lateral  ganglions  of  the  neck,  and  receive  all  the  lymphatic 
vessels  of  this  region,  and  even  those  of  the  posterior  face  of  the  neck, 
many  from  the  costal  region,  from  the  corresponding  limb,  and  some 
of  those  which  come  from  the  lung,  reascending  from  the  medias- 
tinum. This  region  belongs  to  the  origin  of  the  brachial  plexus,  -for 
which  the  space  between  the  scaleni  muscles  seems  formed.  The 
anterior  branches  of  the  last  four  cervical  nerves,  and  that  of  the  first 
dorsal  nerve,  contribute  to  it,  but  very  simply,  by  an  angular  union  : 
each  of  them  receives  an  anastomotic  filament  from  the  great  sympa- 
thetic nerve.  From  this  point  arise,  the  posterior  thoracic  nerve,  the 
external  respiratory  nerve  of  Charles  Bell,  the  diaphragmatic  nerve, 
which  rests  successively  on  the  external  anterior  and  internal  parts  of 
the  scalenus  anticus  muscle,  and  all  the  other  branches  of  the  superfi- 
cial cervical  plexus,  which  is  itself  situated  in  the  sterno-mastoid  region. 
Some  of  these  branches  descend,  as  the  supra-clavicular,  the  supra- 
acromial,  and  the  deep  cervical  nerves ;  others  ascend,  as  the  mastoid, 
the  auricular,  and  the  superficial  or  sub-cutaneous  cervical  nerves, 
which  also  proceed  forward :  the  spinal  nerve  is  simple,  or  divided 
into  several  filaments,  passes  through  the  upper  part  of  the  supra- 
clavicular  space,  and  soon  emerges,  to  go  to  the  trapezius  muscle. 
But  little  fat  exists  in  this  part :  the  cellular  tissue  is  very  loose  in 
every  part  except  between  the  skin  and  the  platysma  muscle. 

2.  Relations,  We  have  stated  the  most  important  arrangements  of 
the  organs  we  have  mentioned,  and  those  which  are  least  known  :  we 
,shall  now  attend  to  their  connexions.  The  first  layer  is  formed  by 


SUPRA-CLAVICULAR   REGION.  133 

the  skin,  which  moves  easily,  not  only  over  the  platysma,  but  far  below 
it :  next  comes  a  thin  but  dense  layer  of  cellular  tissue,  which  inti- 
mately unites  the  skin  with  the  platysma  muscle ;  this  forms  a  third 
plane,  with  a  cellular  layer,  in  which  it  terminates  posteriorly.  Below, 
is  a  layer  formed  by  the  descending  filaments  of  the  cervical  plexus, 
which  are  single  inferiorly,  but  united  to  the  spinal  nerve  above,  and 
to  the  external  jugular  vein  anteriorly.  This  latter,  in  terminating, 
passes  through  the  following  layer,  formed  by  the  scapulo-hyoideus 
muscle,  the  deep  layer  of  the  cervical  aponeurosis  anteriorly,  a  dense 
cellular  layer  posteriorly.  Below,  at  a  distance  from  the  clavicle,  and 
in  the  direction  mentioned,  are  situated  the  transverse  cervical  and  the 
superior  scapular  arteries,  the  subclavian  vein,  which  is  hardly  per- 
ceptible, it  is  so  entirely  concealed  between  the  first  rib  and  the 
clavicle.  In  a  still  deeper  layer,  appears  anteriorly  the  scalenus  anticus 
muscle,  crossed  by  the  phrenic  nerve,  and  on  which  the  small  ascending 
cervical  artery  rests ;  posteriorly,  the  scalenus  posticus  muscle,  which  is 
divided  into  several  distinct  fasciculi.  In  the  space  between  these  two 
muscles,  we  find  the  origin  of  the  brachial  plexus,  which  rests  against 
the  scalenus  posticus,  and  is  situated  at  the  upper  and  outer  part  of 
the  triangular  space :  below,  on  the  first  rib,  the  axillary  artery  rests 
against  the  posterior  side  of  the  scalenus  anticus,  being  separated  from 
the  vein  by  this  muscle,  and  from  the  brachial  plexus  by  a  marked 
cellular  space  :  farther,  these  parts  are  united  by  a  very  loose  cellular 
tissue,  which  is  not  adipose.  Finally,  under  the  scaleni,  we  find,  the 
transverse  processes,  and  the  vertebral  artery  which  enters  into  their 
canal  at  a  height  which  varies,  the  last  inter-transversarii  muscles, 
and  the  deep  cervical  artery  between  the  sixth  and  seventh  transverse 
processes.* 

Development.  The  development  of  this  region  follows  that  of  the 
clavicle,  and  of  the  neck  in  general. 

Varieties.  This  part  presents  several  important  varieties :  they 
relate  to  its  height,  and  the  more  or  less  abnormal  arrangement  of  the 
vessels  and  of  some  muscles.  In  the  motions  of  depressing  the  shoulder 
and  of  drawing  it  forward,  this  region  enlarges  very  much,  and  its 
principal  artery  is  seen  in  a  greater  extent :  opposite  motions  produce 


*  Such  is  our  idea  of  the  supra-clavicular  region  in  the  normal  state,  and  as  it  was  described 
by  Beclard  :  it  is  formed  of  all  the  organs  situated  at  the  base  of  the  supra-clavicular  space, 
the  limits  of  which  are  so  well  defined.  Thus  presented,  this  region  is  simple,  natural,  and 
admits  very  readily  of  applications  in  a  surgical  point  of  view  ;  but  its  character  is  entirely 
changed,  if  we  include  in  it  the  sterno-mastoid  muscle,  a  part  of  the  trapezius,  and  the  pos- 
terior muscles  of  the  neck  :  in  other  words,  if  it  be  bounded  by  lines  drawn  from  the  sterno- 
clavicular  articulation  to  the  anterior  part  of  the  mastoid  process,  and  from  the  posterior  part 
of  this  latter  to  the  acromio-clavicular  articulation. 


134  TOPOGRAPHICAL    ANATOMY. 

in  it  an  opposite  arrangement.  In  inspiration,  the  supra-clavicular 
sinus  of  the  pleura  ascends  higher :  sometimes  the  transverse  cervical 
artery  arises  from  the  axillary  artery  in  the  space  between  the  scaleni, 
or  even  on  the  outside  of  this  space.  In  these  two  cases,  it  commonly 
passes  through  the  meshes  of  the  brachial  plexus ;  at  other  times,  as 
in  plate  third,  the  two  terminating  branches  united  at  their  origin  in 
the  normal  state,  arise  separately ;  one,  the  superficial  branch  of  the 
subclavian  artery ;  the  other,  the  deep  twig  of  the  axillary  artery,  be- 
tween the  sealeni  muscles.  The  superior  scapular  artery  sometimes" 
presents  this  latter  arrangement :  it  is  often  a  remote  branch  of  the 
transverse  cervical  artery,  and  then  it  is  not  situated  in  the  supra- 
clavicular  space.  The  vertebral  artery  often  enters  into  the  canal  of 
the  transverse  processes  unusually  high  :  the  passage  of  the  vein  with 
the  axillary  artery,  in  the  space  between  the  scaleni,  is  very  rare  :  we 
have  seen  it  once.  The  scapulo-hyoideus  muscle  sometimes  terminates 
in  this  region  on  the  clavicle  :  sometimes,  also,  the  scalenus-medius 
muscle  of  Sosmmering  separates  the  brachial  plexus  into  two  fasciculi : 
it  is  rarely  interposed  entirely  between  the  artery  and  the  nerves. 

Pathological  and  operative  deductions.     Wounds  of  the  supra- 
clavicular  region  may  be  extremely  serious  :  they  may  be  immediately 
fatal,  if  the  principal  arterial  trunk  is  opened :  a  severe  hemorrhage 
may  also  result  from  the  injury  of  the  transverse  cervical  and  superior 
scapular  arteries.     The  position  of  this  latter  exposes  it  to  be  opened 
by  the  fragments  of  a  fractured  clavicle,  if  they  are  pushed  back  with 
violence.     An  injury  of  the  brachial  plexus  is  attended  with  severe 
pains,  and  a  more  or  less  perfect  paralysis  of  the  corresponding  extre- 
mity :  it  may  be  injured  by  wounds  of  the  posterior  part  of  the  space. 
A  difficulty  of  respiration  indicates  a  wound  of  the  diaphragmatic 
nerve  anteriorly.     Finally,  in  inspiration,  and  when  the  shoulder  is 
depressed,  a  wounding  instrument,  carried  even  horizontally  to  the 
clavicle,  might  injure  the  axillary  artery,  and  open  the  cavity  of  the 
pleura,  in  the  space  between  the  scaleni :  still  more  would  this  pene- 
trating wound  produce  the  same  symptoms,  if  the  instrument  should 
act  in  the  same  place  obliquely  downward  and  inward.     In  persons 
affected  with  phthisis,  the  deep  lymphatic  ganglions  of  the  supra- 
clavicular  space  are  often  engorged :  this  is  explained  by  the  anato- 
mical  fact  that  these  ganglions   receive  some  lymphatic   vessels  of 
the  lungs.     Tumors  of  this  region,  appearing  in  the  lymphatic  gan- 
glions, or  only  in  the  cellular  tissue,  point  towards  the  skin,  if  situated 
on  the  outside  of  the  aponeurosis,  but  proceed  to  the  axilla  if  covered  by 
this  aponeurosis.     Abscesses  present  these  characters  to  a  great  degree  ; 
they  should,  therefore,  even  when  superficial,  be  opened  early,  lest  they 
should  burrow  through  the  aponeurosis,  and  descend  into  the  axilla. 


SUPRA-CLAVICULAR  REGION.  135 

Superficial  incisions  in  this  part,  if  not  contra- indicated,  should  be 
perpendicular,  in  order  riot  to  wound  many  of  the  superficial  nerves  : 
deep  incisions  should  be  transverse,  to  avoid  the  transverse  cervical 
and  superior  scapular  arteries.  These  incisions  always  cause  pains, 
which  the  patients  refer  to  the  top  of  the  shoulder,  according  to  the 
course  of  the  supra-acromial  nerves.  As  this  region  contains  the  origin 
of  the  brachial  plexus,  we  must  here  apply  leeches,  blisters,  &c<,  when 
we  wish  to  act  on  this  plexus,  in  paralysis  of  the  thoracic  extremity. 
The  portion  of  the  external  jugular  vein  which  occupies  this  point, 
should  be  compressed  in  bleeding  from  the  neck  ;  but  it  is  never  opened 
here,  because  it  is  situated  too  deeply.  The  axillary  artery,  the  pul- 
sations of  which  are  readily  felt  through  the  skin  on  the  first  rib,  may 
also  be  compressed  here  in  operations  on  the  arm.  To  attain  this,  it 
is  necessary,  as  when  we  wish  to  tie  it,  to  depress  the  top  of  the 
shoulder,  and  draw  it  forward  ;  then  to  press  with  the  finger  from  above 
downward,  and  a  little  from  without  inward,  so  as  to  act  perpendicu- 
larly to  the  rib  ;  we  thus  place  the  artery  between  two  opposite  planes 
of  resistance,  one  of  them  passive,  the  other  essentially  active.  This 
compression,  also,  may  be  made  with  an  instrument ;  but  the  finger  is 
preferable.  In  cases  where  the  principal  artery  is  wounded,  it  might, 
perhaps,  be  imprudent  to  lay  it  open  in  order  to  tie  it.  In  fact,  the 
mere  enlargement  of  the  external  wound  might  destroy  the  patient, 
before  the  vessel  could  be  tied  :  it  would  be  better  to  compress  it  on 
the  first  rib.  The  ligature  of  this  trunk  is  indicated  particularly  in 
aneurisms  of  the  axilla ;  but  in  these  cases,  the  clavicle  is  often 
crowded  so  much  upward,  that  the  operation  is  impossible,  the  supra- 
clavicular  space  being  very  much  contracted.  To  prove  this,  we  shall 
merely  mention  that  Sir  Astley  Cooper  was  obliged  to  renounce  it  in 
this  case.  Farther,  to  lay  bare  this  vessel,  a  vertical  or  transverse 
incision  has  been  recommended.  We  have  already  shown  by  anatomy, 
that  if  the  first  exposes  the  supra-clavicular  nerves  less  than  the  second, 
the  transverse  cervical  and  superior  scapular  arteries  are  more  liable 
to  be  wounded.  For  these  reasons,  we  prefer  the  transverse  incision. 
It  should  not  be  made  too  near  the  clavicle,  in  order  to  avoid  the 
superior  scapular  artery,  nor  more  than  one  finger's  breadth  from  it, 
lest  the  transverse  cervical  artery  be  divided.  The  layers,  which  are 
divided  from  without  inward,  are,  the  skin,  the  platysma,  and  the 
supra-clavicular  filaments  of  the1  cervical  plexus  :  we  then  push  inward 
the  lower  extremity  of  the  external  jugular  vein,  with  the  scapulo- 
hyoideus  muscle  ;  we  divide  a  fibro-cellular  layer,  which  is  situated 
on  the  posterior  part  of  this  muscle,  and  we  soon  meet  anteriorly  with 
the  scalenus  anticus  muscle  ;  this  is  followed  to  the  first  rib,  and  behind 
it  we  there  find  the  artery,  which  is  raised  from  within  outward  by 


136  TOPOGRAPHICAL    ANATOMY. 

introducing  one  of  the  fingers  into  the  wound  to  meet  the  director, 
and  prevent  it  from  injuring  the  plexus,  or  from  raising  one  of  its 
branches  :  the  loose  cellular  tissue  which  surrounds  this  vessel  facili- 
tates this  last  period  of  the  operation.  Nevertheless,  during  this  ope- 
ration, the  patient  experiences  severe  pains,  which  dart  down  into  the 
corresponding  limb,  and  even  to  the  ends  of  the  fingers.  This  phe- 
nomenon is  caused  by  disturbing  the  brachial  plexus.  In  order  to 
facilitate  this  operation,  we  must  divide  the  whole  or  a  part  of  the 
scalenus  anticus  muscle.  If  we  should  do  this,  as  Dupuytren  advises, 
we  must  be  careful,  in  the  first  case,  in  dividing  the  muscle,  not  to  cut 
the  phrenic  nerve,  which  is  situated  on  its  inner  part.  If  this  nerve 
should  be  divided,  the  diaphragm  would  lose  its  contractile  power  on 
the  corresponding  side ;  if  simply  the  external  part  of  the  scalenus 
muscle  should  be  divided,  this  accident  would  be  avoided:  this  pre- 
caution may  be  dispensed  with.  We  can  then  conceive,  that  in  tying 
the  axillary  artery,  how  necessary  it  is  to  remember  the  anatomical 
varieties  which  have  been  pointed  out ;  for  if,  on  raising  the  axillary 
artery,  we  perceive  that  it  gives  off  a  large  branch  near  the  place 
where  it  is  to  be  tied,  the  ligature  must  be  applied  above  this  origin, 
or  upon  the  trunk  and  the  branch  which  arises  from  it :  for  want  of 
this  precaution,  a  hemorrhage  may  supervene,  as  when  the  external 
iliac  artery  has  been  tied  below  the  epigastric,  although,  however,  the 
anatomical  relations  are  not  exactly  the  same.  If  the  scapulo-hyoideus 
muscle  impedes  the  operation,  it  must  be  raised  on  a  director  and 
divided.  We  shall  speak  hereafter  of  the  ligature  of  the  subclavian 
artery  on  the  inside  of  the  scaleni  muscles. 


PARAGRAPH       SECOND. 


ARTIFICIAL    AND    COMPLIMENTARY    REGIONS    OF    THE    TRACHEAL    PORTION    OF    THE    NECK. 

These  regions  are  two ;  one  of  them  is  formed  by  the  group  of  organs 
which  rest  on  the  two  faces  of  the  sterno-mastoideus  muscle,  the 
other,  by  the  union  of  those  which  surround  the  primitive  carotid 
artery  below,  and  the  internal  carotid  which  is  continuous  with  the 
former,  above.  -A  little  reflection  will  show  the  importance  of  this 
division  to  complete  the  topography  of  the  neck,  and  in  order  not  to 
separate  the  relations  of  the  carotid  artery  and  sterno-mastoid  muscle ;  we 
think  it  will  be  advantageous  to  students,  because  it  will  assist  the 
memory,  and  practitioners  will  find  it  of  great  surgical  importance. 


STERNO-MASTOID  REGION.  137 


1.      STERNO-MASTOID      REGION. 

This  region  has  extremely  definite  limits  ;  it  is  bounded  anteriorly 
and  posteriorly  by  the  anterior  and  posterior  prominent  edges  of  the 
sterno-mastoideus  muscle,  above  by  the  mastoid  process  of  the  temporal 
bone,  and  below  by  the  sternum  and  the  clavicle.  Its  form  is  that  of 
a  very  elongated  rectangle,  and  its  direction  is  oblique  downward  and 
forward,  so  that  it  passes  almost  from  the  anterior  to  the  posterior  part 
of  the  neck.  Farther,  we  observe  that  it  is  formed  by  the  group  of 
organs  which  correspond  to  the  two  faces  of  the  sterno-mastoideus 
muscle,  when  the  head  is  elevated  on  the  spine,  and  the  face  is  di- 
rected forward. 

The  sterno-mastoid  region  on  the  outside  forms  a  prominence  which 
is  more  or  less  marked  in  its  whole  extent  by  the  muscle  which 
serves  as  its  base.  In  dyspnoea  we  remark  on  its  centre  a  line  which 
crosses  it  from  above  downward  and-  from  before  backward ;  it  is  the 
prominence  of  the  external  jugular  vein. 

Structure,  —  I.  Elements.  The  lateral  face  of  the  cervical  ver- 
tebrae corresponds  to  this  region  in  almost  every  part,  but  the  anterior 
face  corresponds  to  it  only  at  the  lower  part,  of  which,  however,  the 
sterno-mastoideus  muscle  forms  the  base.  Numerous  other  organs  are 
found  in  it,  but  in  so  small  an  extent  that  we  shall  not  enumerate 
them ;  their  description  offers  nothing  peculiar  to  topographical  ana- 
tomy ;  we  will  only  remark  that  the  cervical  plexus,  improperly  called  the 
superficial,  occupies  this  point,  with  a  chain  of  lymphatic  ganglions, 
which  are  called  the  sub-sterno-mastoid. 

2.  Relations.  The  relations  are  very  simple  on  the  outside  of  the 
sterno-mastoideus  muscle ;  the  organs  form  there  very  distinct  layers, 
but  this  is  not  the  case  below  it, ;  we  however  think  that  if  presented 
methodically,  the  structure  of  this  part  may  be  understood  by  every 
one. 

1.  On  the  outside  of  the  sterno-mastoideus  muscle,  we  find  succes- 
sively, a  first  layer  formed  by  a  thin  skin  covered  at  most  with  a  slight 
down:  next  a  cellulo-fatty  tissue  of  a  moderate  degree  of  density;  a 
third  layer  formed  in  the  centre  by  the  platysma,  below  by  the  superfi- 
cial layer  of  the  cervical  aponeurosis,  above  by  a  very  dense  cellular 
tissue,  which  however  is  not  lamellar ;  below  this  layer,  and  in  the 
centre  of  the  region,  a  loose  cellular  tissue  which  is  never  adipose,  and 
in  which  proceed  from  above  downward,  and  from  before  backward, 
the  external  jugular  vein,  and  the  cutaneous  cervical  filaments  of  the 
cervical  plexus,  which  filaments  cross  the  vein,  interlacing  in  the 

18 


133  TOPOGRAPHICAL  ANATOMY. 

centre  of  the  neck ;  the  auricular  filament  from  the  same  plexus 
ascends  perpendicularly,  above  the  centre  of  the  region,  in  this  same 
cellular  tissue.  Finally,  another  layer  is  formed  by  the  sterno-mastoi- 
deus  muscle,  and  through  the  inner  half  of  this  the  spinal  nerve 
passes. 

2.  Below  the  sterno-mastoideus  muscle,  the  relations  must  be  studied 
inf&ribrly  below  the  scapulo-hyoideus  muscle  ;  .in  the  centre,  between 
this  muscle  and  the  mastoid  portion  of  the  splenius ;  and  superiorly 
on  a  level  with  the  latter. 

Inferiorly  we  find  a  very  loose  cellular  layer,  which  is  not  adipose, 
and  in  which  the  curved  portion  of  the  external  anterior  jugular  vein 
passes  near  the  clavicle  ;  next  come  the  deep  layer  of  the  cervical  apo- 
neurosis,  and  the  scapulo-hyoideus  muscle  to  which  it  is  united :  then, 
on  a  level  with  the  external  fasciculus  of  the  sterno-mastoideus  muscle, 
a  portion  of  the  carotid  region,  which  we  shall  examine  hereafter:  but 
at  the  clavicular  portion  of  the  same  muscle,  we  perceive ;  the  sub- 
cla,vian  vein  below,  and  then  rising  successively,  the  supra-scapular 
and  transverse  cervical  arteries,  surrounded  with  lymphatic  ganglions, 
.more  deeply  the  scalenus-anticus  muscle,  crossed  by  the  phrenic  nerve, 
and  placed  on  the  inside  near  the  inferior  thyroid  artery.  All  these  parts 
being  raised,  we  come  to  the  subclavian  artery,  when  it  has  arrived  at 
the  first  rib,  and  has  given  off  all  its  normal  branches ;  it  is  situated 
more  superficially  on  the  right  side,  and  its  origin  on  this  side  also  is 
near  the  brachio-cephalic  trunk  ;  the  thoracic  canal  crosses  posteriorly 
that  of  the  left  side: 

In  the  centre,  under  the  sterno-mastoideus  muscle,  we  find  the  super- 
ficial cervical  nervous  plexus,  between  which  a  number  of  lymphatic 
ganglions  are  situated ;  below,  the  ascending  cervical  branch  of  the 
inferior  thyroid  artery,  the  insertion  in  the  transverse  processes  of  the 
rectus  capitis  anticus  major,  the  scaleni,  the  levator  anguli  scapulae, 
and  the;  splenius  colli  muscles ;  then  the  transverse  processes,  and  the 
vertebral  artery  in  their  canal. 

Superiorly,  when  the  sterno-mastoideus  muscle  is  raised,  we  observe 
a  first  layer  formed  simply  by  the  splenius  capitis  muscle:  below,  a 
second  formed  anteriorly  by  the  posterior  extremity  of  the  digastricus 
and  the  complexus  minor  muscles,  posteriorly  by  the  occipital  artery 
and  veins  which  come  from  below. the  complexus  minor  muscle,  by 
the  atloidal  extremity  of  the  two  oblique  muscles  of  the  head,  and  the 
outer  edge  of  the  complexus  major  muscle  :  under  the  complexus  minor, 
a  portion  of  the  occipital  vessels,  then  the  rectus-capitis-lateralis,  and 
finally  the  vertebral  artery  between  the  atlas  and  occipital  bone. 

Varieties.     Sometimes  two  external  jugular  veins  exist.:  (PI.  III.) 
The  transverse  cervical  and  superior  scapular  arteries  often  arise  out 


STERNO-MASTOID  REGION.  139 

of  this  region  in  the  supra-clavicular  region ;  this  has  been  mentioned 
already. 

Pathological  and  operative  deductions.  It  follows  from  our  re- 
marks, that  wounds  of  the  sterno-mastoid  region  are  particularly  dan- 
gerous at  the  lower  part,  because  if  they  are  deep,  they  may  be 
attended  with  the  lesion  of  the  carotid  artery  and  subclavian  vessels : 
in  the  centre  the  cervical  plexus  may  be  injured,  and  above,  the  occi- 
pital vessels  and  the  vertebral  artery ;  the  vertebral  artery,  however, 
is  more  easily  wounded  between  the  atlas  and  the  axis,  where  it 
forms  a  curve,  which  places  it  on  a  level  with  the  summit  of  the 
transverse  processes.  It  has  been  recommended  to  tie  the  subelavian 
artery  at  the  lower  part  of  this .  region  on  the  trachea!  edge  of  the 
scalenus-anticus  muscle :  this  operation  is  difficult  on  account  of  the 
depth  of  the  vessel,  and  particularly  because  of  the  nearness  of  the 
carotid  artery  and  the  union  of  the  subclavian  and  jugular  veins  ;  this 
operation,  in  our  opinion  is  rash,  since  the  subclavian  artery  cannot 
be  reached  until  it  has  given  off  all  its  branches  ;  and  as  these  serve 
to  restore  the  circulation  of  the  corresponding  limb,  they  necessarily 
preserve  the  blood  fluid  in  the  trunk  as  far  as  the  ligature;  hence, 
when  it  comes  off,  hemorrhage  is  almost  inevitable.  .  Farther,  to  give 
an  idea  of  the  difficulty  of  this  operation,  we  will  add,  that  to  perform 
it  we  must  divide  successively ;  the  skinr  the  superficial  layer  of  the 
cervical  aponeurosis,  the  sterno-mastoideus  muscle,  and  the  deep  layer 
of  the  cervical  aponeurosis  :  we  must  avoid  the  anterior  jugular  vein 
which  passes  through  this  latter  and  push  forward  the  subclavian  vein, 
the  supra-scapular  and  transverse  cervical  arteries  upward,  leave  on 
the  inside  the  internal  jugular  vein  and  the  inferior  thyroid  artery,  and 
then  only  can  we  raise  the  artery  on  the  inside  of  the  scalenus-anticus 
muscle,  being  careful  also  not  to  take  in  front  of  it  the  phrenic  and 
pneumo-gastric  nerves,  and  behind  it  the  thoracic  canal  on  the  left.  *  In 
this  region,  the  external  jugular  vein  is  opened  when  we  wish  to  bleed 
from  the  neck,  but  we  must  not  open  it  directly  in  the  centre  of  the 
neck,  in  order  to  avoid  the  superficial  cervical  nerves.  The  sterno- 
mastoideus  muscle  is  often  pushed  outward  by  ganglionnary  tumors, 
which  are  generally  symptomatic.  Supra-sternal  and  supra-clavicular 
abscesses  burrow  easily  from  one  of  these  regions  into  the  other,  fol- 
lowing the  deep  layer  of  the  cervical  aponeurosis  below  the  sterno- 
mastoideus  muscle  :  we  have  seen  several  instances  of  this.  Finally, 
it  has  been  advised  to  divide-  the  sternb-mastoideus  muscle  at  the  base 
of  this  region  in  cases  of  permanent  rotation  of  the  head,  which  is 
caused  sometimes  by  a  convulsive  contraction,  and  sometimes  by  the 
paralysis  of  one  of  these  muscles.  In  the  first  case,  it  is  recommended 
to  divide  the  convulsed  muscle,  in  the  second  that  which  is  paralyzed : 


140  TOPOGRAPHICAL    ANATOMY. 

in  the  former  case,  the  operation  may  succeed,  but  in  the  latter,  the 
head  will  be  rotated  in  the  opposite  direction,  by  the  sound  and  healthy 
muscle.  The  inferior  and  deep  relations  of  the  sterno-mastoideus 
muscle  show  the  necessity  of  dividing  it  upon  a  director,  to  avoid  the 
large  vessels  below  it.  Boyer  thinks  that  this  operation  is  rarely  indi- 
cated. Richerand,  however,  has  frequently  performed  it  and  with  success. 


2.     CAROTID     REGION. 

This  important  region  is  formed  of  all  the  organs  which  surround 
the  primitive  carotid  artery  and  its  internal  branch ;  it  represents  a 
triangular  space,  the  boundaries  of  which  are  determined  as  follows  : 
posteriorly  by  the  vertebral  column  and  the  rectus  capitis  anticus  major 
and  longus  colli  muscles  :  internally,  by  the  pharynx  above,  the  eso- 
phagus and  trachea  below;  anteriorly  and  externally,  by  the  parotid 
region  and  the  internal  pterygoid  muscle  above,  and  by  the  sterno- 
mastoid  region  below  and  in  the  centre.  This  region,  which  is  thus 
natural  to  a  certain  extent,  extends  the  length  of  the  neck ;  it  proceeds 
from  the  base  of  the  skull  to  the  thorax. 

Structure. — I.  Elements,  Not  to  mention  the  numerous  organs 
included  in  the  carotid  space,  it  is  occupied  by  the  carotid  artery,  which 
ascends  a  little  obliquely  on  the  outside  to  just  below  the  larynx,  and 
is  situated  in  a  perpendicular  plane  above :  on  leaving  this  point,  it 
divides  into  two  branches :  one  is  superficial,  and  goes  to  the  parotid 
region ;  the  other  is  deep,  continues  in  the  course  of  the  trunk,  and 
forms,  towards  the  skull,  a  variable  number  of  more  or  less  distinct 
curves.  Most  of  the  branches  of  this  large  vessel  have  received  special 
names.  Two  smaller,  but  remarkable  arteries,  pass  through  the 
carotid  space ;  one  is  the  inferior  thyroid,  which  presents  there  a  ver- 
tical and  a  transverse  portion  :  the  other  is  the  inferior  pharyngeal 
artery,  The  carotid  artery  is  attended  by  its  vein,  the  internal  ju- 
gular vein,  which  receives  at  the  upper  part,  above  the  larynx,  the 
facial,  lingual,  pharyngeal  and  occipital  veins,  and  a  twig  of  commu- 
nication from  the  external  and  the  anterior  jugular  veins  ;  the  internal 
jugular  vein  receives  only  at  its  lower  part  the  last  two ;  and  in  the 
centre,  the  lateral  thyroid  veins.  In  fine,  the  internal  jugular  vein  cor- 
responds exactly  to  the  carotid  arteries,  only  those  of  its  branches 
which  correspond  to  the  divisions  of  the  external  carotid  artery,  do 
not  unite  in  one  trunk,  but  open  into  the  jugular  vein  at  different 
heights.  Numerous  lymphatic  ganglions  occupy  the  carotid  space, 
below  the  level  of  the  angle  of  the  jaw :  they  are  very  rare  superiorly, 


CAROTID  REGION.  141 

but  are  not  entirely  deficient  there.*  The  pneumo-gastric  nerve  passes 
completely  through  this  region,  and  sends  off  superiorly  its  pharyngeal 
and  superior  laryngoeal  filaments,  and  inferiorly  the  cardiac :  the  cer- 
vical portion  of  the  great  sympathetic  nerve  also  exists  there  in  every 
part,  giving  off  externally  filaments  of  communication  to  the  cervical 
nerves,  internally  the  superficial  and  middle  cardiac  nerves,  and  ante- 
riorly, the  carotid  and  pharyngeal  filaments.  The  great  hypo-glossal 
nerve  and  its  descending  filament,  which  is  a  continuation  of  it  below, 
the  glosso-pharyngeal  and  the  spinal  nerves,  are  the  other  nervous 
parts  of  the  carotid  region.  All  the  elements  are  united  by  a  very 
loose  cellular  tissue,  forming  perhaps  an  external  sheath  for  the  carotid 
artery.  There  is  no  fat  in  this  region. 

2.  Relations.  To  proceed  methodically,  we  must  examine  succes- 
sively the  parietes  of  the  carotid  region,  and  the  relations  of  the  parts 
within  it. 

The  parietes,  in  most  points,  are  known  to  us,  as  they  are  formed 
by  the  regions  already  described.  The  posterior  wall  is  formed  by  the 
anterior  face  of  the  spine,  which  is  covered  by  the  rectus  capitis  anticus 
major  and  the  longus  colli  muscles.  The  internal  wall  is  formed  by 
the  union  of  the  pharyngeal  and  laryngo-tracheal  regions.  The  ex- 
ternal and  anterior  wall  belongs,  superiorly,  to  the  parotid  region, 
and  to  the  masseteric  portion  of  the  malar  region ;  inferiorly,  it  is 
formed  by  the  lower  part  of  the  sterno-mastoid  region ;  but  in  the 
centre,  in  a  triangular  space  which  is  bounded  posteriorly  by  the 
prominence  of  the  sterno-mastoideus,  on  the  inside  by  the  larynx,  and 
superiorly  by  the  angle  of  the  jaw,  it  is  formed  of  thin  layers,  in  which 
the  carotid  vessels  are  superficially  situated.  These  layers  have  not  yet 
been  described.  In  proceeding  from  without  inward,  we  find  in  this 
point,  the  skin,  a  thin  cellular  layer,  the  platysma,  the  superficial  cervical 
nerves  of  the  cervical  plexus  anteriorly,  the  auricular  nerve  from  the 
same  plexus  posteriorly,  the  external  jugular  vein  passing  on  the  out- 
side of  the  digastricus  muscle,  and  sending  from  above  downward 
under  it,  a  twig  towards  the  internal  jugular  vein  or  one  of  its  branches. 
The  digastricus  and  the  stylo-hyoideus  muscles  being  raised  above, 
we  come  in  every  part  to  a  venous  plexus,  in  the  meshes  of  which  are 
numerous  lymphatic  ganglions ;  this  plexus  is  formed  by  the  facial, 
lingual,  pharyngeal,  laryngoeal,  superior  thyroid,  and  occipital  veins, 
and  the  twigs  of  communication  between  the  external  and  anterior 
jugular  veins  with  the  internal.  Below  this  venous  net-work,  we  see 
the  reflected  portion  of  the  hypo-glossal  nerve,  the  trunk  of  the  external 

*  Must  we  conclude  from  the  small  number  of  lymphatic  ganglions  existing  under  the  base 
of  the  skull,  that  the  brain  has  no  lymphatic  vessels,  and  that  the  few  which  come  from  this 
cavity,  belong  to  the  meninges  ? 


142  TOPOGRAPHICAL  ANATOMY. 

carotid  artery  and  its  principal  branches, 'some  of  which  diverge  ante- 
riorly, as  the  superior  thyroid,  the  lingual,  and  the  facial  arteries ; 
another,  the  occipital,  is  directed  a  little  obliquely  backward.  The 
relations  of  the  organs  of  the  carotid  space  are  very  simple :  we  find 
in  every  part  of  it  the  primitive  carotid,  and  its  continuation,  the  in- 
ternal carotid  artery,  which  rest  against  the  internal  -wall  of  the  space ; 
near  them  is  the  internal  jugular  vein.  If  we  separate  these  two 
vessels  slightly,  we  discover  between  and  behind  them,  the  pneumo- 
gastric -and  the  great  sympathetic  nerves ;  this  latter  on  the  outside  ot 
the  former.  In  the  highest  part  of  the  carotid  space,  the.  principal 
artery  is  near  anteriorly  and 'on  the  Inside  to  the  inferior  pharyngeal 
artery,  which  comes  from  the.  external  carotid  artery:  the  spinal, 
great  hypo-glossal,  and  the  glosso-pharyngeal  nerves,  are  united  at 
first  to  the  pneumo-gastric  and  great  sympathetic  nerves  in  the  space 
between  the  carotid  artery  and  jugular  vein  :  but  on  a  level  with  the 
atlas,  the  relations  change  ;  the  spinal  nerve  goes  obliquely  backward 
and  passes  before  the  jugular  vein  ;  the  glosso-pharyngeal  and  great 
hypo-glossal  nerve,  the  latter  lower  than  the  former,  cross  the  anterior 
part  of  the  carotid  artery,  and  go  inward :  finally,  in  this  upper  portion 
of  the  carotid  region,  the  pharyngeal  and  superior  .laryngosal  filaments 
of  the  pneumo-gastric  nerve,  always  glide  behind  the  carotid  artery  in 
this  upper  portion  of  the  carotid  region,  to  go  to  their  destination  :  in 
the  centre  of  the  neck,  the  carotid  artery  is  directly  in  contact  on  -the 
outside,  with  the  descending  branch  of  the  great  hypo-glossal  nerve, 
which  soon  unites  in  an  arch,  with  the  internal  descending  branch  of 
the  cervical  plexus,  which  branch  passes  in  its  turn  obliquely  before 
the  internal  jugular  vein  :  near  this  -point,  an  arterial  twig-,  which 
leaves  the  superior  thyroid  artery,  and  goes  to  the  sterno-mastoid 
muscle,  passes  obliquely  through  this  region,  crossing  the  direction  of 
the  principal  vessels :  a  little  below,  a  lateral  vein  proceeds  from  the 
thyroid  gland  toward  the  internal'  jugular  vein,  passing  transversely 
before  the  carotid  ar.tery,  which  is  covered. also  by  the  thyroid  gland  : 
the  transverse  portion  of  the  inferior  thyroid  :artery,  on  which  the 
middle  cervical  ganglion  rests,  crosses  posteriorly  the  direction  of  the 
vessels  and  nerves. 

Development.  At  puberty,  the  internal  and  external  carotid  arteries 
are  nearly  of  the  same  size ;  before  this  period,  the  internal  is  larger 
in 'proportion  to  the  external,  the  nearer  we  approach  to  the  period  of 
birth  and  that  of  conception  :  this  fact  may  be  explained  by  the  unequal 
development,  at  these  different  ages,  of  the  organs  to  which  these  two 
vessels  go.  In  the  child  and  the  fetus,  the  curves  of  the  internal 
carotid  artery  are  very  distinct ;  they  disappear  in  part  as  age  advances, 
and  it  would  seem  that  the  artery  always  possessed  its  normal  length 


CAROTID  REGION.  143 

when  first  formed,  and  that  it  was  folded  only  to  accommodate  itself 
to  the  extent  of  the  neck  at  this  period. 

Varieties.  In  the. female,  the  internal  carotid  artery  is  smaller  in 
proportion  to  the  external,  than  in  the  male. 

A.Burns  has  cited  some  cases  where  the  primitive  carotid  artery 
continued  under  the  skull,  before  dividing.  We  have  never  seen  this 
variety  ;  but -we  have  often  observed  that  the -external  carotid  artery 
arose  from  it  at  the  angle  of  the  jaw :.  in  these  cases,  the  superior 
thyroid  and  the  lingual  artery  did  not  come  from  it,  but  from  the 
primitive  carotid  artery.  Burns  also  mentions  the  premature  division 
of  this  artery.  We  have  seen  the  inferior  thyroid  artery  come  from 
the  primitive  carotid  at  the  thyroid  gland.  Finally,  when  speaking 
of  the  laryngo-tracheal  region,  we  mentioned  the  passage  of  the  pre- 
ceding vessel  before  the  carotid  artery  in  a  case  where  its  origin  was 
normal.  The  superior  thyroid  artery  may.  arise  from  the  primitive 
carotid  artery  high  up.  Finally,  the  common  carotid  artery  may 
present  a  great  number  of  curious' varieties  in  its  origin,  which  we 
shall  pass  over,  because  they  do  not  affect  the  region  of  which  we  are 
speaking.  Sometimes  we  find  in  the  adult  the  internal  carotid  artery 
curved  in  the  form  of  an  S,  as  in  the  child ;  we  obtained  a  specimen 
of  this  from  the  dissecting  rooms  of  the  faculty. 

Uses.  The  position  of  the  carotid  vessels  in  a  broad  space,  filled 
with  a  loose  cellular  tissue,  is  one  of  those  minute  precautions  taken 
by  nature  to  give  the  utmost  possible  liberty  to  the  circulation  of  the 
head,  the  organs  in  which '  are  so  important.  In  the  carotid  space, 
however,  the  tortuous  arrangement  of  the  artery,  under  the  skull,* 
visibly  tends  to  diminish  the  force  of  the  circulation  in  the  delicate 
substance  of  the  brain  ;  doubtless,  also,  the  same  cause  may  be  assigned 
for  the  greater,  curves  of  this  vessel  in  the  child  and  the  fetus,  in  whom 
the  brain  is  very  much  developed,  and  at  the  same  time  very  soft,  and. 
therefore  requires  to  be  protected  from  the  velocity  of  the  circulation, 
particularly  at  this  age.  • 

Pathological  and  operative  deductions.  .Wounds  of  the  centre  of 
the  carotid  space  may  be  very  serious,  although  they  are  not  deep  ;  to 
be  satisfied  of  this,  it  is  only  necessary  to  place  the  finger  on  the  side  of 
the  larynx:  we  feel  there  almost  immediately  the  pulsations  of  the 
primitive  carotid  artery,  which  might  thus  be  easily  wounded.  Absces- 
ses or  effusions  of  blood  in  this  region  very  promptly  extend  upward 

*  In  most  of  the  carnivorous  mammalia,  the  internal  carotid  artery  presents  under  the  brain 
an  arrangement  which  will  give  an  idea  of  the  uses  of  its  curves  in  man.  It  divides  into  a 
great  number  of  branches,  which  afterwards  reunite  and  form  a  ne.w  trunk.  These  different 
branches  anastomose  in  a  plexus  around  the  pituitary  body  and  form  the  rete  mirabUe  of 
authors. 


144  TOPOGRAPHICAL    ANATOMY. 

and  downward  toward  the  mediastinum,  from  the  very  great  laxity  of 
the  cellular  tissue,  and  also  because  prevented  by  no  fibrous  layer.  The 
lymphatic  ganglions  which  have  been  mentioned,  often  swell  in  diseases 
of  the  head  or  neck ;  those  situated  under  the  angle  of  the  jaw  are  enlarged 
in  inflammation  of  the  isthmus  of  the  fauces,  because  they  receive  all 
the  lymphatic  vessels  which  come  from  this  point.  Their  position  near 
the  nerves  and  vessels,  explains  the  compression  which  they  sometimes 
exercise  upon  them,  and  the  dyspnoea*  or  the  obstruction  to  the  circula- 
tion in  the  brain  caused  by  them.  We  have  found  in  the  upper  part  of  the 
right  pneumo-gastric  nerve,  in  a  subject  brought  to  the  dissecting  rooms, 
a  tuberculous  mass  as  large  as  a  pea ;  we  could  learn  nothing  in  regard 
to  the  symptoms  during  life.  This  individual  had  doubtless  been  affect- 
ed with  dyspnoea,  as  in  animals  where  in  physiological  experiments,  one 
of  the  par  vagum  nerves  had  been  divided,  or  as  in  the  patient  observed 
by  Andral.  The  ligature  of  the  primitive  carotid  artery  is  not  difficult, 
but  the  above  details  must  be  remembered ;  this  vessel  has  often  been 
tied  for  aneurisms  or  fungous  tumors,  or  to  prevent  hemorrhage  when  the 
artery  or  its  branches  have  been  wounded.  Upon  whatever  part  of  the 
neck  this  operation  is  performed,  we  must  always  make  the  incision 
before  the  sterno-mastoideus,  and  divide  successively  the  skin,  the  pla- 
tysma  myoides  muscle  superiorly,  inferiorly  the  superficial  layer  of  the 
cervical  aponeusoris,  ajid  its  deep  layer  under  the  scapulo-hyoideus 
muscle,  the  latter  may  be  divided  if  it  is  in  the  way,  and  also  the  sterno- 
mastoid  twig  of  the  superior  thyroid  artery  ;  we  must  also  remember 
the  position  of  the  lateral  thyroid  veins  when  they  exist,  and  the  variety 
where  the  inferior  thyroid  artery  passes  before  the  carotid ;  we  must 
then  carefully  open  the  sheath  of  the  carotid  artery,  avoid  the  descend- 
ing branch  of  the  great  hypo-glossal  nerve,  and  push  the  artery  from 
without  inward,  in  order  not  to  take  up  with  it  the  internal  jugular  vein, 
and  the  pneumo-gastric  and  great  sympathetic  nerves  which  are  near 
it,  the  first  on  the  outside,  the  last  two  outward  and  backward.  We 
must  not  carry  the  instrument  for  taking  up  the  vessel  too  near  the 
vertebral  column,  lest  the  inferior  thyroid  artery  be  injured,  on  which 
it  rests  below.  Wardrop  has  treated  an  aneurism  of  the  primitive 
carotid  successfully,  by  tying  this  artery  between  the  tumor  and  the 
capillary  system.  This  is  the  first  successful  case  for  which  the  carotid 
artery  is  better  adapted  than  any  other :  in  fact  it  gives  off  no  branch 
before  its  bifurcation,  the  blood  circulates  there  contrary  to  the  direc- 
tion of  its  specific  gravity,  and  the  circulation  of  the  head  after  the 
operation  is  not  for  a  moment  interrupted,  on  account  of  the  numerous 

*  Andral  in  the  Bulletins  de  i'  Jlthenee  de  mcdecine,  July  1826,  mentions  a  case  where  the 
pneumogastric  nerves  were  wasted,  by  being  compressed  by  the  tumefied  lymphatic  ganglions. 
The  patient  in  the  latter  periods  of  life  was  affected  with  a  remarkable  dyspnoea. 


REGION  OP  THE  NUCHA.  145 

anastomoses  of  the  arteries ;  all  these  circumstances  easily  admit  the 
coagulation  of  the  blood  in  the  artery  and  tumor  below  the  liga- 
ture. We  think  that  now,  a  surgeon  should  be  censured,  if  he  should 
permit  a  patient  to  die  rather  than  imitate  the  remarkable  example  of 
Wardrop.  The  primitive  carotid  artery  was  tied  for  the  first  time  by 
Sir  Astley  Cooper ;  Dubois,  however,  would  have  performed  it  before 
him,  had  not  the  patient  died  from  an  attack  of  apoplexy,  some  days 
before  that  appointed  for  the  operation.  We  may  be  called  to  tie  the 
external  carotid  artery  at  its  origin  in  cases  of  wounds,  or  following  the 
example  of  Beclard,  or  in  order  to  extirpate  the  parotid  gland  more 
safely.  To  tie  this  vessel,  we  must  divide  the  skin,  the  platysma  muscle, 
and  some  nervous  filaments  of  the  cervical  plexus  ;  we  must  then  look 
for  it  below  and  between  the  meshes  of  the  venous  plexus,  which  has 
been  mentioned  as  existing  under  the  angle  of  the  jaw. 


ARTICLE       II. 


POSTERIOR   PORTION   OF   THE   NECK. 

This  is  formed  by  the  group  of  organs  which  rest  on  the  spinal  face 
of  the  upper  part  of  the  spine,  and  presents  but  one  very  simple  region, 
that  of  the  nucha,  the  cervical  region  of  Chaussier. 


REGION      OF      THE      NUCHA. 

The  nucha,  cervix,  has  very  definite  limits  ;  the  external  occipital 
protuberance  above,  the  spinous  process  of  the  atlas  below,  and  la- 
terally, the  edges  of  the  sterno-mastoideus  and  trapezius  muscles,  which 
also  bound  the  sterno-mastoid  and  supra-clavicular  regions. 

The  region  of  the  nucha  is  concave  from  above  downward,  and  con- 
vex transversely;  its  transverse  diameter  is  contracted  in  the  centre, 
and  gradually  enlarges  as  we  approach  the  skull  or  the  back. 

Most  of  the  deep  face  of  this  region  rests  on  the  spine,  except  above, 
where  it  is  connected  with  the  portion  of  the  region  of  the  base  of  the 
skull,  intercepted  between  the  occipital  foramen  and  the  external  occi- 
pital protuberance,  Its  superficial  face  is  loose,  cutaneous,  and  covered 

19 


146  TOPOGRAPHICAL   ANATOMY. 

with  hairs  in  its  upper  third.  On  the  median  line,  the  raphe  is  very 
distinct,  and  we  can  here  feel  the  summits  of  the  spinous  processes  of 
the  vertebrae,  particularly  at  the  lower,  part ;  at  the  upper  part  the 
occipital  protuberance  always  exists  on  the  median  line,  and  at  the 
lower  part,  on  the  prolongation  of  the  plane  of  the  occipital  foramen, 
is  a  depression  which  varies  in  depth,  a  kind  of  cervical  fossa. 

Structure.  —  1.  Elements.  The  annular  part  of  the  cervical 
vertebrae  forms  the  skeleton  of  this  region,  to  which,  consequently, 
the  cervical  portion  of  the  vertebral  canal  belongs.  We  remark,  that 
the  vertebral  layers  are  very  distinct  from  each  other,  particularly  at 
the  upper  part ;  that  the  yellow  ligaments  which  fill  their  spaces,  are 
easily  perceived  posteriorly,  when  all  the  muscular  parts  are  removed, 
and  that  on  their  level,  the  parietes  of  the  vertebral  canal  are  weak. 
The  posterior  cervical  ligament  exists  in  man,*  although  as  a  rudiment, 
and  is  attached  to  the  external  occipital  crest  and  protuberance  above, 
and  to  the  summit  of  the  last  cervical  spinous  processes  below.  The 
nucha  is  particularly  remarkable  for  its  numerous  muscles  :  some 
belong  to  it  entirely,  and  others  in  part.  The  first  are  the  inter- 
spinales,  the  posterior  inter-transversarii,  the  recti  and  obliqui  muscles, 
and  the  superior  fasciculi  of  the  transversalis  colli  muscles.  Among 
the  second  may  be  mentioned,  the  two  cornplexi,t  the  splenius,  the 
transversalis  colli,  and  the  levator  anguli  scapulas  muscles,  which 
extend  but  little  below  the  nucha ;  the  trapezius,  the  rhomboideus,  the 
serratus  minor  posticus  superior,  and  the  upper  extremity  of  the 
sacro-lumbalis,  which  exist  in  this 'region  in  but  a  small  part  of  their 
extent. 

Four  considerable  arteries  send  branches  into  the  region  of  the 
nucha :  the  vertebral,  the  deep  and  the  transverse  cervical,  and  the 
occipital  arteries.  The  first  two  are  deep  seated  ;  the  vertebral  presents 
there  its  last  curve,  and  the  deep  cervical  terminates  there.  The  last 
two  are  superficial,  and  of  them,  only  the  horizontal  portion  of  the 
trunk,  and  the  origin  of  the  last  curve  of  the  occipital  artery,  exist 
there.  All  these  arteries  anastomose  extensively  with  each  other, 
and  establish  vascular  communications  between  the  carotid  artery 


*  In  the  large  quadrupeds,  this  ligament  is  enormous.  It  is  formed  of  a  very  elastic  yellow 
fibrous  tissue,  and  forms  a  spring,  which,  by  its  elasticity  alone,  straightens  the  head  on  the 
spine,  while  it  does  not  prevent  the  head  from  being  flexed  towards  the  neck  by  the  power 
of  the  muscles. 

f  The  complexus  major  muscle  may  be  considered  as  a  transversalis  colli  muscle  :  its  direc- 
tions, insertions,  and  uses,  are  the  same.  If  we  call  to  mind  the  analogy  of  the  occipital  bone 
and  of  the  vertebra,  this  comparison  of  the  muscles  will  become  still  more  striking.  This 
muscle,  however,  contrary  to  the  opinion  of  authors,  is  not  inserted  in  the  transverse  processes, 
but  in  a.  groove  which  separates  them  from  the  articular  processes. 


REGION  OF  THE  NUCHA.  147 

from  which  the  last  arises,  and  the  subclavian  artery,  which  gives  off 
the- first  three.  The  veins  accompany  the  arteries.  The  deep  lym- 
phatie  vessels  all  go  to  the  lateral  lymphatic  ganglions  of  the  neck : 
the  superficial  vessels,  on  the  contrary,  are  divided  between  the  pre- 
ceding ganglions  and  those  of  the  axilla. 

The  nerves  of  the  nucha  come  almost  exclusively  from  the  posterior 
branches  of  the  sub-occipital  nerve,  and  from  the  cervical  nerves, 
which  are  joined  by  the  spinal  nerve,  and  some  descending  filaments 
of  the  superficial  cervical  plexus  :  all  these  nerves,  which  are  at  first 
deep,  become  superficial  as  they  advance,  and  finally  terminate  by 
numerous  twigs  in  the  skin. 

The  cellular  tissue  of  this  region  is  loose  between  the  muscles,  and 
very  dense  under  the  skin :  in  this  last  point,  also,  it  is  much  more 
compact  above  than  below,  which  renders  the  dissection  of  the  muscles 
of  this  part  very  difficult.  Notwithstanding  its  density,  this  cellular 
tissue  has  no  lamellar  arrangement,  and  it  is  an  abuse  of  the  term 
aponeurosis  to  call  it  so,  by  showing  its  continuity  with  the  fascia 
cervicalis.  Fat  exists,  particularly,  in  the  sub-cutaneous  tissue,  and 
perhaps  also  deeply  behind  the  occipital  foramen  ;  generally  speaking, 
it  is  not  abundant.  The  skin  is  firmer  and  thicker  than  upon  the 
tracheal  portion  of  the  neck :  it  is  hairy  and  very  follicular  at  the 
upper  part. 

2.  Relations.  In  proceeding  from  the  skin  toward  the  spine,  we 
discover,  successively ;  in  the  nuchal  region,  a  layer  of  skin,  a  cellulo- 
fatty  tissue,  which  is  very  dense,  particularly  at  the  upper  part, 
attaching  the  skin  to  the  deeper  layers  very  firmly,  and  containing, 
directly  under  the  occipital  bone,  the  ascending  portion  of  the  occipital 
vessels,  with  a  considerable  nervous  filament,  which  attends  them  to 
the  occipito-frontal  region  ;  next,  we  find  a  fleshy  layer,  formed  by  the 
trapezius  and  sterno-mastoideus  muscles,  between  which  the  preceding 
nerves  and  vessels  pass  upward ;  these  two  muscles,  however,  are  not 
contiguous,  and  between  them  we  see  in  this  layer  a  part  of  the 
splenius  and  of  the  levator  anguli  scapulae  muscle :  a  second  fleshy 
layer,  which  lies  under  the  trapezius  and  the  sterno-mastoideus  mus- 
cles, is  formed  from  above  downward, .  by  a  part  of  the  complexus 
major,  the  splenius,  the  levator  anguli  scapulas,  the  upper  part  of  the 
rhomboideus  muscle,  and  that  of  the  serratus  posticus  superior,  which 
passes  beyond  the  first ;  if  the  last  two  be  removed,  the  lower  extremity 
of  the  splenius  may  be  perceived,  and  also  the  highest  fasciculi  of  the 
sacro-lumbalis  muscle.  Next,  comes  a  third  fleshy  layer:  it  is  visible 
when  we  have  turned  outward  the  levator  anguli  scapulas  muscle,  and 
have  entirely  removed  the  splenius  ;  it  seems  formed,  in  almost  every 
part,  by  the  complexus  major  and  minor,  which  rests  on  the  former, 


148  TOPOGRAPHICAL  ANATOMY. 

below  also  by  the  complexus  minor,  by  the  transversalis  colli,  and  by 
the  sacro-lumbalis,  the  three  united  and  almost  blended  in  one  fascicu- 
lus :  below  the  complexus  major  muscle  is  an  interstice  which  is  more 
cellular  than  the  others,  which  interstice  contains  the  deep  nerves  and 
vessels  of  the  region,  the  ascending  'part  of  the  deep  cervical  artery, 
the  branches  of  the  vertebral  artery,  and  the  posterior  twigs  of  all  the 
cervical  nerves  :  below,  is  a  fourth  muscular  layer  formed ;  at  the 
lower  part,  by  the  superior  fasciculi  of  the  transversarii  muscles ; 
above,  by  the  two  oblique  and  the  posterior  recti  muscles  of  the  head  ; 
the  first  two  muscles,  with  the  rectus  major  muscle,  form  a  triangular' 
space,  the  base  of  which  corresponds  to  the  posterior  occipito-atloidal 
ligament,  to  the  posterior  arch  of  the  atlas,  and  in  the  area  of  which 
appear  the  last  curve  of  the  vertebral  artery,  the  twigs  which  it  sends 
into  the  neck  and  the  posterior  filaments  of  the  sub-occipital  nerve. 
Finally,  all  these  parts  being  removed,  the  posterior  face  of  the  spine 
is  exposed  at  the  upper  part,  we  can  discern  there  the  distinctness  of  its 
layers  and  the  breadth  of  its  inter-laminar  spaces,  which  arrangement 
shows  at  the  posterior  part  the  yellow  ligaments. 

Development.  The  development  of  this  region  presents  nothing- 
peculiar.  The  sub-occipital  fossa  is  more  and  more  distinct,  in  pro- 
portion to  the  age.  It  is  very  much  marked  in  the  old  man,  on 
account  of  his  thinness,  and  also  because  the  head  being  inclined 
forward,  requires  a  continual  muscular  effort  to  prevent  it  from  falling- 
entirely  forward,  in  consequence  of  which,  the  muscles  which  circum- 
scribe this  depression  become  more  prominent. 

Varieties.  In  porters,  this  highly  muscular  region  is  very  much 
developed  ;  but  its  development  is  slight  in  females  and  children.  Its 
upper  transverse  extent  is  in  relation  with  that  of  the  posterior  part  of 
the  skull  on  which  it  rests.  Some  persons,  by  examining  this  point, 
have  pretended  to  be  able  to  determine  the  genital  powers  of  different 
individuals,  in  accordance  with  the  opinion  of  Gall,  who  considers  the 
cerebellum  as  regulating  this  function.  When  the  neck  is  extended, 
this  region  is  shortened,  but  it  is  lengthened  when  the  neck  is  flexed. 

Pathological  and  operative  deductions.  Wounds  of  the  nucha  are 
not  dangerous  when  they  are  superficial.  The  slight  hemorrhage 
with  which  they  are  attended  is  always  easily  arrested  by  compression 
or  by  applying  a  ligature.  Deep  wounds  may  be  very  serious,  arid  even 
immediately  fatal.  A  pointed  instrument  may  in  fact  penetrate  be- 
tween the  layers  of  the  vertebrae  to  the  vertebral  canal ;  this  is  parti- 
cularly easy  at  the  level  of  the  sub-occipital  fossa,  between  the  Occiput 
and  the  atlas,  or  between  this  last  and  the  axis.  The  weakness  of  the 
wall  of  the  vertebral  canal  in  this  point  seems  to  be  generally  known, 
for  it  has  several  times  been  selected  by  murderers  for  the  fulfilment 


CHEST.  149 

of  their  criminal  designs.  Fractures  of  the  vertebral  layers  are  rare 
in  this  region,  because  they  are  protected  by  the  muscles  more  than 
in  any  other  part,  and  because  the  very  short  spinous  processes  are 
not  superficial,  and  are  concealed  between  this  latter,  and  hence  coun- 
terblows are  less  frequent.  We  have  mentioned  in  another  place  our 
ideas  upon  dislocations.  Anthrax  or  furonculae,  appear  frequently 
in  this  region.  These  tumors  cause  there  pains,  which  are  more  in- 
tense in  proportion  to  the  internal  adhesion  of  the  skin  to  the  subjacent 
parts.  The  nucha  is  connected  with  the  orbital  region  by  sympathies, 
which  cannot  be  demonstrated  satisfactorily  by  anatomy,  but  which, 
however,  are  not  less  real,  as  daily  observation  will  show;  hence, 
the  propriety  of  selecting  this  region  for  applying  issues  in  affections 
of  the  orbit,  and  particularly  in  ophthalmia.  When  the  inflammation 
produced  by  these  causes  is  very  acute,  the  lateral  ganglions  of  the 
neck  are  swelled,  because  these  organs  receive  the  lymphatic  vessels 
of  the  neck.  When  a  seton  is  applied  to  this  part,  we  must  be  careful 
not  to  wound  the  muscles ;  we  have  known  tetanus  and  death  to  be 
caused  by  their  injury.  The  hemorrhage  which  sometimes  ensues 
after  this  operation,  from  the  superficial  ramifications  of  the  occipital 
and  transverse  cervical  arteries,  can  always  be  arrested  by  compression. 


CHAPTER      II. 


OP     THE      CHEST. 

The  chest,  pectus,  thorax,  is  that  important  portion  of  the  trunk 
which,  in  the  mammalia,  specially  protects  the  respiratory  organs,  the 
heart,  and  its  principal  vessels.  Its  external  limits  are  fixed  and  well 
defined :  the  extremity  of  the  sternum,  and  the  edge  of  the  first  rib, 
which  may  be  readily  felt  on  the  limits  of  the  neck,  at  the  upper  part ; 
at  the  lower,  the  base  of  the  bony  chest,  which  is  represented  on  the 
right  and  left  by  a  curved  line,  very  prominent  anteriorly,  less  so 
posteriorly :  this  line  is  the  upper  boundary  of  the  abdomen. 

The  chest  is  situated  at  the  union  of  the  upper  third  with  the  two 
lower  thirds  of  the  body.  Its  direction  is  oblique  from  above  down- 
ward and  from  behind  forward  ;  this  arrangement  must  be  seen  by  an 
examination  made  anteriorly  and  on  the  sides,  for  the  posterior  part 


150  TOPOGRAPHICAL  ANATOMY. 

of  this  portion  of  the  trunk  describes  an  arch*of  a  circle,  the  cord  of 
which  is  perpendicular,  and  the  convexity  is  directed  backward. 

The  form  of  this  region,  when  the  shoulders  are  not  considered, 
may  be  referred  to  that  of  a  truncated  cone,  the  base  of  which  is  at 
the  lower  part.  Its  height,  breadth,  and  thickness,  are  estimated  by 
considering  the  transverse,  vertical  and  antero-posterior  diameters : 
their  absolute  length  varies,  and  is  of  but  slight  importance :  this  is 
not  true  of  their  relative  extent.  The  vertical  diameter  is  larger  on 
the  outside,  at  the  level  of  the  ribs,  and  a  little  smaller  posteriorly, 
near  the  spine,  still  smaller  at  the  height  of  the  sternum,  and  always 
exceeds  the  last  two.  The  transverse  diameter,  in  the  normal  state  and 
the  adult,  is  larger,  in  turn,  than  the  antero-posterior.*  Farther,  we 
remark,  that  these  diameters,  when  measured  externally,  a,re  far  from 
furnishing  the  -capacity  of.  the  thorax  by  their  measurement :  .the  con- 
vexity of  the  spine  on  the  inside,  and  that  of  the  diaphragm  also,  show 
it.  The  thoracic  portion  of  the  trunk  presents  a  cavity,  which  is 
separated  into  two  secondary  cavities  by  a  median  septum.  The  term 
chest  sometimes  designates  the  cavity  alone,  although  we  cannot  con- 
ceive of  it  without  the  parietes  which  form  it.  It  is  flattened  from 
before  backward,  supporting  above,  and  on  the  outside,  the  shoulder, 
with  which  it  forms  the  axilla.  It  presents  nothing  general  but  the 
raphe,  which  is  distinctly  marked. 

Structure.  The  skeleton  of  the  chest  is  formed  entirely  by  the  thorax ; 
its  muscles  are  intrinsic  .or  extrinsic :  among  these  latter  the  most  re- 
markable go  toward  the  shoulder,  and  concur  by  their  angular  separa- 
tion of  the  thorax,  to  form  the  a'xilla.  Vessels,  nerves,  &c.,  are  found  here 
as  in  every  other  part.  The  relations  present  nothing  general ;  the  ex- 
treme layers  are  the  skin  on  one  side,  the  pleura  'on  the  other.  Finally, 
this  region  presents  two  distinct  portions,  the  pectoral  -and  the  abdo- 
minothoracic. 

Development.  The  development  of  the  chest  resembles  that  of  the 
trunk  in  general ;  it  occurs  by  two  pieces,  which  are  first  separated 
laterally,  and  afterwards  united  on  the  raphe  ;  when  once  formed,  the 
antero-posterior  diameter  is  very  much  developed  during  the  whole  of 
pregnancy,  and  in  some  measure  at  the  expense  of  the  other  two  ;  this 
arrangement  depends  on  the  great  flexion  of  the  spine  anteriorly,  and 
on  the  premature  development  of  the  organs  situated  in  the  cavity  on 
the  median  line.  After  birth,  the  transverse  diameter  suddenly  increa- 
ses, on  account  of  the  establishment  of  respiration :  but  at  puberty  par- 
•  ticularly,  this  diameter  is  enlarged,  so  as  to  exceed  in  the  adult  the 
anteroLposterior  diameter. 

*  This  arrangement  exists  only  in  man. 


CHEST.  151 

Varieties.  In  the  old  man,  as  the  spine  again  bends  forward,  the 
articulations  of  the  ribs  become  rigid,  these  bones  are  depressed  on  the 
spine,  the  antero-posterior  diameter  becomes  proportionally  and  even 
absolutely  larger  than  the  others. 

In  the  female,  especially  anteriorly,  the  height  of  the  c'hest,  compared 
with  that  of  the  body,  is  a  little  less  than  in  the  male ;  the  antero-pos- 
terior diameter  is  proportionally  more  extensive  than  the  transverse  ; 
notwithstanding  its  apparent  slope  above,  the  chest  in  the  female  still 
retains  the  form  of  a  cone,  the  base  of  which  is  situated  at  the  lower 
part,  the  superior  transverse  extent  not  depending  upon  a  real  enlarge- 
ment in  this  point,  but  on  the  greater  separation.of  the  shoulders,  which 
is  caused  by  the  length  of  the  clavicles.  We  see  also  that  the  chest  of 
the  female  preserves  many  of  the  characters  of  infancy. 

Individual  variations  are  perhaps  more  numerous  here  than  in  any 
other  parts ;  sometimes  the  antero-posterior  diameter  is  very  much  de- 
veloped at  the  expense  of  the  transverse,  or  the  latter  at  the  expense 
of  the  former  ;  the  respiration  in  those  individuals  in  whom  the  first 
conformatibn  exists,  is  very  difficult ;  they  are  disposed  to  phthisis  ;  the 
second  type  has  a  marked  influence  on  the  circulation,  and  disposes  to 
diseases  of  the  heart ;  some  males  have  the  chest  of  the  female,  and 
vice  versa. 

Uses.  The  chest,  by  the  parietes  of  its  cavity,  serves  as  a  protecting 
organ  ;  farther,  it  moves  very  remarkably  in  respiration  ;  and  although 
these  motions  are  not  connected  with  our  subject^  we  must  not  only  men- 
tion their  existence,  but  also  the  progressive  diminution  of  their  extent,, 
from  birth  to  old  age.  We  shall  see  hereafter  the  pathological  deduc- 
tions from  these  opinions. 

Pathological  and  operative  deductions.  The  thoracic  portion  of 
the  trunk  may  'sometimes  be  entirely  deficient,  as  in  the  athoraco- 
cephalic  fetuses  :  sometimes  its  upper  half  only  is  deficient,  in  the  pec- 
toral portion,  as  in  apectoro-cephalia.  We  not  unfrequently  observe  a, 
want  of  union  on  the  median  line,  either  in  one  point  or -in  nearly  the 
whole  of  the  chest;  hence  anterior  or  posterior  fissures.  Rachitis-often 
produces  in  the  skeleton  of  this,  portion  of  the  trunk  different  deformi- 
ties, in  which  all  its  parts  participate ;  the  most  frequent  is  a  curve  to 
the  left,  by  which  the  two  thoracic  cavities  are  considerably  contracted, 
on  the  left,  side  by  the  approximation  of  the  ribs,  on  the  right,  by  the 
abnormal  prominence  of  the  spine  this  side.- 

These  general  ideas  being  laid  down,  let  us  examine  first  the  parietes 
of  the  thorax,  then  its  cavity,  and  the  organs  which  it  contains. 


152  TOPOGRAPHICAL    ANATOMY. 


ARTICLE       I  . 


OF      THE       PARIETES      OP      THE      THORAX. 


The  parietes  of  the  thorax  are  generally  divided  into  anterior,  pos- 
terior, lateral,  superior,  and  inferior ;  but  this  division  is  much  too 
artificial  to  form  the  regions  of  this  part  of  the  trunk.  These  regions, 
moulded  on  the  skeleton,  are  six  in  number,  exclusive  of  that  of  the 
mediastinum,  which  will  be  examined  when  speaking  of  the  cavity  of 
the  thorax  :  they  are  the  two  costal,  the  sternal,  the  dorsal,  and  the 
diaphragmatic  regions,  and  that  of  the  upper  wall. 


1.     COSTAL      REGIOtf. 

Most  of  the  circumference  of  the  chest  is  formed  by  the  ribs  and  the 
organs  which  rest  on  them  or  are  situated  in  their  interstices ;  they 
constitute  the  costal  region,  which  is  extended  on  the  anterior  and  pos- 
terior faces  of  the  trunk,  and  corresponds  particularly  to  its  lateral 
part. 

Its  limits  are  very  exact ;  they  are  anteriorly  the  heads  of  the 
sternum  and  the  sternal  region  ;  posteriorly  and  deeply  the  vertebral 
column,  and  more  superficially,  the  external  prominence  of  the  sacro- 
spinalis  muscle  in  strong  individuals ;  above  and  below,  the  upper  and 
lower  edges  of  the  first  and  twelfth  ribs. 

The  surface  of  this  region  is  convex  and  directed  obliquely  from 
above  downward  and  from  within  outward  ;  it  is  remarkably  high  in 
the  centre,  and  on  leaving  that,  point  it  diminishes  progressively  ante- 
riorly and  posteriorly.  The  costal  region  is  thinner  forward  and  at 
the  base  than  in  any  other  portion  ;  at  the  upper  part  its  thickness  is 
increased  by  that  of  the  shoulder  which  it  supports. 

The  costal  region  presents  two  faces ;  one  of  them  is  internal,  is 
concave,  smooth,  and  is  lined  by  the  pleura ;  the  other,  the  external,  is 
convex,  cutaneous  in  most  of  its  extent,  except  above,  where  it  forms 
one  of  the  parietes  of  the  axilla.  This  face,  on  the  anterior  and  poste- 
rior part  of  this  region,  is  raised  and  rendered  plane  by  the  fleshy 
masses  which  are  detached  angularly  to  go  to  the  shoulder,  and  which 
thus  form  the  parietes  of  the  axilla  ;  anteriorly,  this  cutaneous  face  of 
the  costal  region  presents  the  relief  of  the  inferior  edge  of  the  pectoralis 


COSTAL  REGION.  153 

major  muscle,  and  below  some  oblique  prominences,  which  mark  the 
digitations  of  the  serratus  major  muscle,  which  prominences  are  seen 
in  the  works  of  painters  and  sculptors;  We  shall  mention  hereafter 
the  mammae,  a  small  distinct  region,  a  sort  of  appendix  to  this. 

Structure. — -1.  Elements.  This  region  rests  on  the  ribs  and  their 
cartilages  which  form  its  skeleton ;  these  parts  leave  between  them 
spaces  which  are  broader  above  and  at  the  union  of  the  rib  with  its 
cartilage,  and  longer,  on  the  contrary,  in  the  centre,  than  in  any  other 
part;  'Each  rib  is  extended  forward^  and  articulated,  as  has  been  said, 
with  the  sternum,  or  with  the  two  other  ribs  between  which  it  is  situ- 
ated. This  latter  arrangement  is  peculiar  to  the  false  ribs,  the  carti- 
lages of  which  are  articulated  by  special  facetts,  and  are  united  by 
some  loose  fibrous  attachments  ;  in  these  points,  the  intercostal  spaces 
do  not  exist.  The  posterior  articulation  is  formed  by  the  contact  of 
the  ribs  with  the  bodies  of  the  vertebrae  and  their  transverse  processes, 
on  which  they  form  an  arch  posteriorly ;  farther  details  belong  to  de- 
scriptive anatomy.  The  muscles  of  this  region  are  situated  in  the 
intercostal  spaces,  under  and  on  the  outside  of  the  ribs.  In  the  inter- 
costal space  we  find  the  two  planes  of  the  intercostal  muscles,  which 
are  composed  of  fleshy  arid  aponeurotic  fibres  and  have  opposite  direc- 
tions ;  the  external  layer  is  directed  from  behind  forward,  and  the  in- 
ternal layer  from  .before  backward  ;  these  circumstances  increase  the 
resistance  of  the  intercostal  spaces.  The  external  layer  does  not  ex- 
tend entirely  to  the  sternum ;  it  is  there  replaced  by  a  strong  aponeu- 
rosis,  the  fibres  of  which  are  directed  like  those  of  the  muscle  ;  the 
same  arrangement  exists  posteriorly  for  the  internal  layer,  which  does 
not  extend  to  the  spine.  Under  the  ribs  we  often  find  some  small 
muscles,  the  infracostales  ;  the  triangularis  sterni  muscle  always  exists 
anteriorly,  the  diaphragm  and  transversalis  abdominis  muscles  bound 
it  below.  On  the  outside  of  the  ribs,  the  serratus  major  muscle  belongs 
entirely  to  this  region,  although  it  terminates  on  the  scapular  region. 
The  two  pectoral  muscles,  the  trapezius,  the  rhomboideus,  the  latis- 
simus  dorsi,  the  serrati,  the  obliquus  abdominis  extern  us,  the  rectus 
abdominis,  and  some  fibres  of  the  platysma  myoides  muscle,  are  also 
situated  in  this  region  in  a  greater  or  less  portion  of  their  extent.  The 
rectus  muscle  is  covered  there  anteriorly,  by  a  prolongation  of  its 
abdominal  sheath.  .The  arteries  of  this  region  are  remarkable  for  their 
arrangement;  they. are  the  infracostal)  the  intercostal,  or  the  extra- 
costal.  The  first  come  from  the  trunk  of  the  internal  mammary  artery, 
which  corresponds  to  the  anterior  part  of  the  region,  superiorly  by  its 
trunk,  inferiorly  by  a  considerable  branch  which  follows  the  circum- 
ference of  the  base  of  the  chest.  The  branches  of  this  vessel  extend 
to  the  internal  portion  of  the  costal  region,  and  farther  to  each  of  its 
20 


154  TOPOGRAPHICAL  ANATOMY. 

intercostal  spaces,  by  two  twigs,  and  finally,  to  the  supracostal  portion, 
by  some  branches  which  penetrate  the  muscles.  The  arteries  of  the 
intercostal  space  are  numerous  :  they  are,  posteriorly,  the  intercostal 
artery  and  a  twig  which  it  sends  towards  the  upper  edge  of  the  inferior 
rib ;  anteriorly,  two  twigs  of  the  mammary  artery  which  anastomose 
with  the  preceding  arteries  ;  all  extend  their  ramifications  toward  the 
pleura,  the  skin,  and  the  intercostal  muscles ;  the  principal  intercostal 
branches  which  come  into  the  skin,  pass  through  the  external  muscles 
in  the  centre  of  the  intercostal  spaces.  The  extracostal  arteries  come 
from  the  trunk  which  goes  to  the  thoracic  extremity,  and  are  given  ofF 
from  the  transverse  cervical  or  the  posterior  scapular  arteries,  the  two 
thoracic  and  the  common  scapular  arteries.  Some  arterial  anastomoses 
which  are  important  to  the  collateral  circulation  exist  in  this  region, 
between  the  intercostal,  the  mammary,  the  posterior  scapular,  the  com- 
mon scapular,  and  the  thoracic  arteries.  Two  veins  generally  accom- 
pany each  artery ;  some  lymphatic  ganglions,  which  are  commonly 
but  slightly  developed,  exist  on  the  course  of  the  intercostal  and  mam- 
mary arteries ;  they  receive  some  superficial  and  a  part  of  the  deep 
seated  lymphatic  vessels.  Most  of  the  superficial  lymphatic  vessels  go 
to  the  axillary  ganglions.  The  nerves  are  intercostal  or  extracostal : 
the  first  send  their  twigs,  like  the  arteries,  not  only  to  the  space  they 
occupy,  but  also  toward  the  pleura  and  the  diaphragm  internally,  and 
towards  the  skin  externally  ;  each  intercostal  nervous  trunk  gives  off 
one  external  trunk  to  the  centre  of  its  space ;  that  of  the  upper  trunk 
belongs  to  the  arm,  the  others  remain  on  the  outside  of  the  region. 
The  extracostal  nerves  come  from  the  brachial  plexus  ;  they  are  the 
thoracic  twigs ;  we  find  there  also  some  supra-clavicular  filaments  of  the 
superficial  cervical  plexus.  The  trunks  of  the  vessels  and  nerves  of  the 
costal  region  are  generally  situated  deeply  ;  their  twigs  usually  pro- 
ceed from  within  outward  and  come  to  the  skin  ;  they  also  give  some 
perhaps  to  the  pleura,  a  circumstance  highly  important  in  the  structure 
of  this  region.  The  cellular  tissue  is  loose  in  every  part,  and  but  little 
adipose  tissue  exists,  except  superiorly  and  anteriorly  ;  we  however 
find  a  little  fat  in  every  part.  The  skin  is  remarkable  only  for  its  sen- 
sibility ;  the  pleura  adheres  but  slightly  and  in  every  part ;  the  mam- 
mary gland  will  be  examined  hereafter. 

2.  Relations.  The  relations  of  the  costal  region  are  complex,  par- 
ticularly on  the  outside  ;  they  are  extremely  important ;  in  order  to 
mention  them  methodically,  we  must  consider  them  successively  in 
the  supracostal,  the  intercostal,  and  the  infracostal  regions. 

1.  Supracostal  portion.  This  should  be  divided  into  two  halves, 
an  upper  and  a  lower.  The  first  is  rendered  more  complex  by  the 
presence  of  the  shoulder ;  if  we  remove  this,  or  rather  if  we  separate  it 


COSTAL  REGION.  155 

from  the  trunk  at  the  axilla,  we  find  from  without  inward ;  first,  the 
posterior  thoracic  vessels  and  nerves  resting  on  the  outer  face  of  the 
serratus  major  muscle  ;  second,  the  serratus  major  muscle,  through 
which  pass  the  brachial  twigs  of  the  intercostal  nerves  and  some  ar- 
teries ;  third,  more  deeply  a  very  loose  cellular  tissue,  then  the  ribs 
and  the  intercostal  spaces.  In  front  of  the  axilla  are  parts  which  go 
toward  the  shoulder  and  form  the  anterior  wall  of  the  axilla,  to  which 
parts  we  shall  attend  hereafter  ;  on  the  inside,  they  present  themselves 
in  the  following  order  ;  the  skin,  a  loose  cellular  'tissue  in  which  we 
find  some  fibres  of  the  platysma  and  the  supra-clavicular  nervous  fila- 
ments, the  mammary  gland,  which  forms  a  small  separate  region,  the 
pectoralis  major  muscle  presenting  a  cellular  interstice  situated  on  a 
line  oblique  downward  and  outward  ;  finally,  under  this  muscle  near 
the  sternum  and  above,  we  come  to  the  ribs  and  their  cartilages,  while 
in  the  centre  is  situated  the  pectoralis  minor  muscle  which  extends  a 
little  below  the  sternum  ;  under  the  pectoralis  'minor  appear  the  first 
portion  of  the  serratus  major  muscle  and  the  ribs.  We  find  behind 
the  shoulder  and  always  in  the  upper  half  of  this  extracostal  portion ; 
the  skin,  a  very  dense  cellular  layer,  a  first  muscular  layer  formed  by 
the  trapezius,  the  rhomboideus,  and  the  latissimus  dorsi;  a  second  layer 
which  includes  the  whole  of  the  rhomboideus  ;  finally,  a  third  formed 
by  the  serratus  minor  muscle.  In  the  lower  half  of  the  extracostal 
portion,  under  the  skin  and  the  sub-cutaneous  cellular  tissue,  through 
which  pass  the  external  filaments  of  the  intercostal  vessels  and  nerves, 
we  find  a  fleshy  layer  formed  from  before  backward  by  the  rectus 
muscle  in  its  sheath,  the  obliquus  externus,  the  lower  anterior  part  of 
the  serratus  posticus  superior  muscle,  and  the  costal  portion  of  the 
latissimus  dorsi  muscle  :  under  these  the  ribs  and  their  spaces  appear 
in  almost  every  part ;  posteriorly,  between  them  and  the  latissimus 
dorsi,  we  see  a  small  part  of  the  serratus  posticus  superior,  and  the 
serratus  posticus  inferior  muscles. 

2.  Intercostal  portion.  Under  the  preceding  layers,  we  find  the 
ribs  and  their  spaces,  which  are  alike  in  every  part,  and  are  closed  by 
two  layers :  one  of  them  is  external ;  it  is  the  external  layer  of  the 
intercostal  muscles,  and  the  aponeurosis,  by  which  it  is  continued 
forward ;  the  other,  the  internal,  is  the  deep  layer  of  the  intercostal 
muscles  and  its  posterior  aponeurosis.  Between  these  two  layers,  the 
vessels  and  nerves  are  situated  posteriorly  at  equal  distances  from  the 
two  ribs,  and  in  the  centre  their  trunks  extend  along  the  upper  rib 
which  slightly  protects  them,  while  one  of  their  branches  follows  the 
upper  edge  of  the  lower  rib,  and  finally,  being  reduced  to  simple  fila- 
ments, they  occupy  the  centre  of  the  space. 

3.  Infracostal  portion.     Under  the  ribs,  and  the  layers  yhich  fill 


156  TOPOGRAPHICAL  ANATOMY. 

their  interstices,  we  come  in  almost  every  part  to  cellular  tissue,  and 
then  to  the  pleura ;  in  some  points,  we  sometimes  find  the  infracostal 
muscular  fasciculi,  and  the  internal  mammary  vessels  always  present 
themselves  anteriorly,  two  lines  from  the  sternum  above,  and  at  its 
edge  below,  where  they  are  protected  by  adjacent  cartilages,  which 
are  united.  Under  these  vessels,  we  find  the  triangularis  sterni  muscle 
below,  and  the  pleura,  to  which  they  are  adjacent,  above. 

Development,  The  costal  region,  and  also  the  ribs  which  constitute 
the  base '  of  it,  form  early ;  but  in  the  earliest  periods,  it  is  flat.  It 
does  not  assume  its  characteristic  convex  form  until  after  birth,  and 
particularly  until  puberty. 

Varieties.  The  pressure  of  corsets  in  females  depresses  this  region 
at  the  lower  part,  which  is  naturally  prominent,  and  causes  it  to 
assume  a  roundness  which  is  greater  at  the  centre  than  above.  The 
costal  region  sometimes  extends  higher,  in  consequence  of  the  deve- 
lopment of  a  thirteenth  upper  or  lower  rib ;  there  is  then  one  more 
intercostal  space.  Sometimes  two  ribs  are  united  in  one,  posteriorly 
or  anteriorly,  which  slightly  modifies  the  intercostal  spaces.  In  fe- 
males, the -costal  region  is  flatter  than  in  males ;  it  is  also  thicker,  on 
account  of  the  predominance  of  fat.  We  not  unfrequently  see  two 
infracostal  arteries,  one  of  which  occupies  the  position  of  the  internal 
mammary  artery,  the  other  glides  under  the  ribs  in  the  centre  of  the 
region  :  this  supernumerary  branch  may  come  from  the  subclavian  or 
from  the  first  intercostal  artery. 

Uses.  All  this  part  is  moved  upward  and  downward,  by  the  ster- 
num, in  the  .motions  of  inspiration  and  of  expiration  :  in  motions 
upward,  the  intercostal  spaces  are  enlarged  ;  they  are  contracted  in 
motions  downward.  The  ribs  cannot  be  carried  backward  by  any 
external  muscle,  on  account  of  the  point  of  support  which  they  have 
on  the  corresponding  transverse  "process  ;  we  must,  however,  except 
the  false  ribs.  The  mobility  of  the  ribs,  considered  separately,  in- 
creases from  above  downward ;  but  viewed  as  connected  by  the  ster- 
num, they  cannot  be  depressed  or  elevated  except  in  an  equal  ratio  }* 
the  ribs,  also,  rotate  around  their  cord,  but  in  the  lower  and  middle 
ribs  this  motion  is  greater  than  in  the  upper  ribs.  These  reflections 
furnish  a  subject  for  important  remarks. 

Pathological  and  operative  deductions.  This  region  is  often  de- 
formed by  rachitis  :  it  may  be  depressed  inward  or  may  project  out- 

*  It  is  evident  that  we  allude  here  to  the  absolute  motion  -performed  by  the  anterior  extre- 
mity of  each  rib,  and  not  to  this  motion  proportional  to  the'length  of 'the  costal  ray  ;  that  the 
first  rib  is  more  fixed,  (an  opinion  admitted  by  Haller,  and  rejected  by  Majemlie,)  appears  to 
us  to  be  proved,  by  the  shortness,  size,  and  resistance  of  the  first  costal  cartilage,  and  also  by 
the  want  of  an  angle  to  this  rib,  which  circumstances  deprive  it  of  the  rotatory  motion  exe- 
cuted by  the  others  around  tlicir  cord, 


COSTAL  REGION.  157 

ward.  When  the  thoracic  portion  of  the  spine  curves  to  the  right  or 
left,  the  costal  region,  corresponding  to  the  side  toward  which  the 
curve  exists,  is  flexed,  the  fibs  approach,  the  intercostal  spaces  become 
very  narrow ;  the  region  bulges,  on  the  contrary,  on  the  opposite  side, 
the  ribs  are  removed  from  each  other,  and  the  intercostal  spaces  become 
broader.  Sometimes  the  costal  region  is  depressed,  so  as  to  become 
convex  internally,  even  when  no  rachitis  exists,  in  persons  who  have 
recovered  from  an  old  thoracic  effusion,-  followed  by  the  crowding 
back  and  the  adhesion  of  the  lung  to  the  mediastinum :  in  fact,  when 
the  liquid  is  absorbed,  the  lung  cannot  dilate  as  quickly  as  the  absorp- 
tion takes  place,  and  then  the  costal  region  inclines  inward,  to  prevent 
a  vacuum.  The  ribs  may  be  fractured  directly,  or  by  the  action  of  a 
pressure  which  increases  their  curve.  In  the  first  case,  the  fragments, 
if  pressed  inward,  may  cause  severe  injuries.  The  upper  ribs,  which 
are  protected  by  the  shoulder  and  the  muscles,  are  rarely  frac- 
tured; this  is  true  also  of  the  lower  ribs,  on  account  of  their 
great  mobility.  The  middle  ribs  are  protected  by  neither  of  these 
causes,  and  hence  they  are  often  fractured.  The  displacement  of  the 
fragments  of  the  fractured  ribs  is  slight,  because  they  are  supported 
by  those  which  are  uninjured  :  the  latissimus  dorsi,  or  the  pectorales 
muscles,  may  nevertheless  draw  one  of  the  fragments  upward :  the 
other  may  be  depressed  by  the  obliquus  externus,  the  rectus,  or  the 
triangularis  sterni  muscle,  according  to  the  rib  which  is  fractured. 
The  very  great  and  constant  mobility  of  the  costal  region,  prevents 
the  union  of  the  fractured  pieces  ;  this,  however,  may  be  counteracted 
by  bandaging  the"  chest  tightly,  so  that  'the  respiration  shall  be  per- 
formed by  the  diaphragm.  Fractures  of  the  costal  cartilages  are  rare, 
on  account  of  their  suppleness  :  their  slight  degree  of  vitality  explains 
why  they  are  imperfectly  united  by  the  formation  of  the  external 
osseous  ring,  which  -keeps  the  fragments  in  place.  When  these  carti- 
lages are  ossified,  however,  their  fractures  unite  like  those  of  the  ribs. 
We  have  seen  instances  of  both  modes  of  union.  W^e  cannot  conceive 
how  the  ribs  can  be  dislocated  posteriorly.  Buttet.  who  has  written  a 
memoir  upon  this  subject,  was  doubtless  deceived  by  a  fracture  of  their 
posterior  parts.  The  cartilages  of  the  last  ribs  sometimes  glide  over 
each  other  anteriorly,  constituting  a  trivial  kind  of  dislocation. 
Wounds  of  this  region,  if  confined  to  the  supracostal  portion,  are 
always  very  slight ;  at  the  upper  part,  however,  they  may  cause 
hemorrhage,  which  may  come  from  the  thoracic  arteries.  If  the 
wound  be  deeper,  the  ribs  or  the  costal  cartilages  may  be  injured  :  the 
wounding  instrument  which  proceeds  from  above  downward,  injures 
the  ribs  much  more  easily  above,  where  one  of  their  faces  looks  up- 
ward, the  other  downward ;  the  lower  ribs,  from  an  opposite  arrange- 


158  TOPOGRAPHICAL  ANATOMY. 

ment,  are  more  easily  wounded  by  an  instrument  which  proceeds 
horizontally.     If  the  wound  penetrates  into  the  intercostal  space,  a 
hemorrhage  may  supervene,  from  an  injury  of  the  intercostal  artery, 
or  of  the  branches  of  the  mammary  artery.     Among  the  modes  em- 
ployed  to   arrest   this   hemorrhage,   simple   plugging  is    preferable. 
When  the  wounding  instrument  acts  near  the  sternum,  and  affects 
most  of  the  anterior  wall,  the  internal  mammary  artery  may  be  opened : 
this  artery  is  more  liable  to  injury  superiorly,  on  account  of  the 
breadth  of  the  intercostal  spaces,  from  its  size,  and  particularly  because 
it  is  situated  two  lines  from  the  sternum ;  it  is  less  liable  to  be  wounded 
below,  from  opposite  reasons,  and  particularly  because  its  nearness  to 
the  edge  of  the  sternum  in  a  measure  protects  it.     We  shall  speak 
hereafter  of  penetrating  wounds,  in  which  this  whole  region  is  inte- 
rested.    The  simultaneous  distribution  of  vessels  and  nerves  from 
common  trunks  to  the  pleura,  the  diaphragm,  and  to  the  skin,  explains 
those  pains  felt  superficially  in  pleurisy,  and  the  efficacy  in  these  cases 
of  leeches  and  counterirritation,  and  emollients  applied  to  the  sides  of 
the  thorax,  and  finally  the  singular  sympathy  which  connects  the  skin 
of  this  region  with  the  diaphragm,  and  the  advantage  taken  of  this 
sympathy  in  asphyxia,  to  re-establish  respiration.     The  operation  of 
empyema  may  be  performed  on  all  the  intercostal  spaces.     Verduc, 
Desault,  and  Boyer,  recommend  the  lowest  parts  to  be  selected,  with 
variations  to  the  right  and  left,  which  we  shall  mention  hereafter. 
Laennec  prefers  the  most  central  space,  because  this  is  the  lowest  part 
in  laying  down  on  the  side.     Farther,  we  must  select  the  exact  centre 
of  the  intercostal  space  :  we  select  the  central  transverse  point,  to 
avoid  posteriorly  the  injury  of  the  twig  of  the  intercostal  artery,  which 
goes  obliquely  toward  the  lower  rib  ;  and  in  order  not  to  wound  ante- 
riorly the  intercostal  artery  itself,  which  leaves  the  lower  rib  ;  we 
prefer  the  central  longitudinal  point,  so  as  not  to  wound  the  intercostal 
artery  above,  or  the  twig  of  this  vessel,  which  extends  along  the  lower 
rib,  below.     This  operation  is  necessarily  attended  with  the  incision 
of  the  skin,  of  a  cellular  layer,  of  the  obliquus  externus,  of  the  serratus 
anticus  superior  muscle,  of  the  intercostales,  the  cellular  tissue  under 
the  pleura,  and  the  pleura.     Senac's  advice  to  puncture  the  pericardi- 
um, by  plunging  a  trochar  into  the  third  intercostal  space,  and  two 
inches  from  the  sternum,  to  avoid  the  internal  mammary  artery,  which 
method  was  followed  by  Desault  with  some  modifications,  should  never 
be  performed,  because,  independent  of  its  exposing  the  heart  to  injury 
when  hydro-pericarditis  does  not  exist,  the  pleura  is  necessarily  opened. 
From  the  costal  region  proceeds  a  small  secondary  region,  which 
completes  the  first,  viz.  that  of  the  mamma.     This  region  is  slight  in 
the  male,  but  is  very  much  developed  in  the  female.     In  works  on 


COSTAL  REGION.  159 

descriptive  anatomy,  we  find  the  fullest  details  in  regard  to  its  form, 
size,  and  position,  the  prominence  of  the  nipple,  its  areola,  the  glands 
near  it,  and  the  depression  which  bounds  this  region  inferiorly. 

Structure.  —  I.  Elements.  We  will  only  mention  that  the  mammary 
region  is  formed  essentially  of  the  mammary  gland  ;  that  its  excretory 
passages  are  united  in  fasciculi  by  a  cellulo-vascular  tissue,  and  form 
the  nipple ;  that  its  granulations  are  united,  in  more  or  less  distinct 
masses,  by  large  cellular  interstices,  and  that  its  circumference  extends 
vaguely  on  the  muscles.  An  abundance  of  fat  and  cellular  tissue 
exists  in  this  region.  It  receives  arteries  from  two  sources  ;  some  come 
to  it  from  above  downward,  and  from  without  inward,  the  thoracic 
vessels  ;  the  others  proceed  from  within  outward ;  these  are  branches 
of  the  internal  mammary  artery,  and  are  fewer.  The  veins  form  two 
layers,  one  is  superficial ;  it  arises  at  the  base  of  the  nipple,  and  its 
twigs  do  not  accompany  the  arteries,  while  the  other  is  deep,  and  pre- 
sents an  opposite  arrangement.  Most  of  the  lymphatic  vessels  go  to 
the  axillary  ganglions  ;  the  deep,  however,  terminate  in  the  internal 
mammary,  and  intercostal  ganglions.  The  nerves  come  from  the  tho- 
racic and  intercostal  twigs,  and  also  from  the  supra-clavicular  filaments 
of  the  cervical  plexus.  The  skin  and  a  small  mucous  membrane  com- 
plete all  the  elements  of  this  region. 

2.  Relations.  The  nipple  is  formed  by  the  mucous  membrane,  a 
cellular  tissue,  which  is  not  adipose  and  very  vascular,  and  which  con- 
tains some  of  the  nerves,  and  the  principal  milk-passages.  In  the  rest 
of  its  extent,  the  region  is  successively  formed,  first  by  the  skin,  and  in 
the  centre  by  the  mucous  membrane  which  is  more  adherent  there  J 
second,  by  a  cellular  and  adipose  tissue,  in  which  the  supra-clavicular 
nerves  are  situated  above,  and  the  veins  and  the  superficial  lymphatic 
vessels  in  every  part ;  next  comes  the  mammary  gland ;  some  cellulo- 
adipose  matter  is  interposed  between  its  lobes,  which  are  united  by 
very  dense,  and  apparently  fibrous,  cellular  bands.  The  gland  itself 
rests  particularly  on  the  pectoralis  major,  and  slightly  on  the  pectoralis 
minor  and  serratus  superior  muscles. 

Development.  This  region  is  rudimentary  in  the  male^  In  the  fe- 
male it  is  developed  only  at  puberty ;  it  collapses  after  the  cessation  of  the 
menses,  and  it  constantly  becomes  at  different  periods  of  life,  the  centre 
of  an  irritation ;  as  at  puberty,  at  each  menstrual  period,  during  gesta- 
tion, and  at  the  turn  of  life  ;  hence  we  can  thus  conceive  of  the  fre- 
quency of  its  morbid  affections.  The  sensibility  of  the  whole  region, 
if  we  except  the  nipple,  is  rather  slight. 

Pathological  and  operative  deductions.  At  the  different  periods  we 
have  mentioned,  this  region  is  often  the  seat  of  an  inflammation,  which 
may  affect  only  the  nipple  and  its  areola.  Abscesses  often  form  in  this 


160  TOPOGRAPHICAL  -ANATOMY. 

region  in  nurses  ;  if  the  inflammation  be  superficial,  it  is  not  serious ; 
but  if  it  is  deep,  pus  infiltrates  between  the  segments  of  the  gland,  dis- 
unites them,  the  latter  become  hard,  and  fistulas  always  exist.  •  Encyst- 
ed tumors  are  often  developed  in  the  mammas  ;  cancer  seems  to  affect 
this  gland  particularly;  it  generally  commences  at  the  base  of  the  nip- 
ple, which  soon  disappears,  being  drawn  inward  by  a  kind  of  contrac- 
tion of  its  cellular  tissue;  and  of  its  passages ;  the  cancerous  tumor  soon 
extends,  and  radiates  like  the  lobes  of  the  gland ;  these  are  the  diverg- 
ing claws  of  the  crab,  to  which  the  ancients  compared  cancer ;  it  is 
worthy.of  remark,  that  cancer  is  always  preceded  by  a  kind  of  fibrous 
change  of  the  interlobular  tissue,  in  which  the  disease  primitively  ap- 
pears. The  axillary  ganglions  are  next  engorged,  and  in  the  later 
periods,  the  mammary  and  intercostal  ganglions  ;  hence  the  pains  under 
the  sternum,  mentioned  by  every  author,  for  which  anatomy  accounts 
satisfactorily.  The. skin  of  this  region  is  very  much  relaxed,  when 
the  arm  is  brought  near  the  trunk;  hence  the  precept,  when  the  axil- 
lary glands  are  not  engorged,  to  operate  on  cancer  of  the  breast  by  in- 
cisions perpendicular  to  the  axis  of  the  body,  in  order  that  union  by  the 
first  intention  may  be  facilitated.  Tumors  in  the  axilla  can  be  extir- 
pated more  easily  by  making  an  incision  obliquely  upward  and  out- 
ward, toward  the  axilla ;  this  operation  causes  the  patient  to  feel  pains 
in  the  neck  in  the  course  of  the  supra-clavicular  nerves,  In  advanced 
cancerSj  the  disease  extends  beyond  the  mammary  region,  attacks  the 
pectorales  muscles,  the  ribs,  and  the  pleura.  If  we  are  bold  enough 
then  to  undertake  the  operation,  ought  the  roots  of  the  evil  to  be  re- 
moved? Should  the  ribs  and  the  pleura  be  amputated  ?  Richerand  has 
resolved  this  difficulty,  by  a  most  remarkable  operation,  and  has  proved 
by  experience,  that  life  may  be  preserved,  notwithstanding  the  pene- 
tration of  air  into  the  chest.  Precautions,  however,  should  be  taken,  to 
prevent  its  continual  ingress. 


2.     STERNAL      REGION. 

The  division  of  the  body  into  -regions  ought  not  to  be  marked  off 
upon  its  anterior  or  posterior  faces  :  otherwise  the  regions  would  be 
all  artificial,  and  the  student  would  suffer  from  the  consequences  of 
this  defective  mode,  and  would  find  the  parts -of  the  body  which  are 
formed  even  very-  naturally,  parcelled  out  in  such  a  manner  as  to 
afford  but  an  imperfect  knowledge  of  them.  We  have  here  an  impor- 
tant instance  of  the  truth  of  this  remark  :  if  the  whole  anterior  wall  of 
the  thorax  should  torm  but  one  region,  we  should  be  obliged  to  refer  to 
this,  the  anterior  part  of  the  intercostal  spaces,  which  it  is  important 


STERNAL  REGION.  161 

to  regard  entire.  These  inconveniences  are  avoided  in  this  point,  by 
comprising  in  the  sternal  region  only  those  parts  which  are  connected 
with  the  sternum,  which  method  is  indicated  by  the  denomination  of 
the  region. 

The  sternal  region,  which  makes  a  part  of  the  anterior  wall  of  the 
thorax,  is  composed  of  the  organs  which  rest  on  the  sternum  anteri- 
orly. Its  length  is  much  less  than  its  breadth  ;  its  thickness  is  less 
inferiorly ;  it  is,  in  fact,  determined  almost  entirely  by  that  of  the  bone. 
Its  limits  are  very  natural  and  are  easily  perceived  externally  ;  they 
are,  superiorly  and  inferiorly,  the  two  extremities  of  the  sternum  ; 
laterally,  the  edges  of  this  bone  which  may  be  felt  by  pressing  upon 
the  superficial  layers.  This  region  is  oblique  downward  and  forward. 

The  sternal  region  presents  two  faces  ;  one  is  cutaneous,  the  other 
is  deep  :  the  first  is  hairy  in  man,  and  is  depressed  longitudinally  at 
the  raphe,  particularly  in  adults  and  very  strong  individuals ;  farther, 
we  remark  a  series  of  transverse  prominences,  the  relief  of  the  edges  of 
the  crest  of  the  sternum :  one  of  them,  the  most  constant,  is  situated 
at  the  union  of  the  upper  with  the  two  lower  thirds  of  the  region  and 
results  from  the  angular  union  of  the  first  pieces  of  bone  :  sometimes, 
but  rarely,  we  feel  a  deep  median  depression,  which  indicates  an  ab- 
normal formation  of  the  bone  ;  a  prominence  appears  at  the  upper 
and  outer  part  of  each  rib  which  belongs  to  the  sterno-clavicular 
articulation.  The  deep  face  of  this  region  is  united  with  the  medias- 
tinum. 

Structure, —  1.  Elements.  The  sternum,  which  is  very  spongy, 
forms  the  base  of  this  region.  Its  ensiform  cartilage  is  frequently  cleft, 
and  it  presents  a  foramen,  which  Dulaurens  and  Riolan  have  wrongly 
considered  as  more  frequent  in  the  female.  This  bone  contributes 
superiorly,  by  a  concave  facet  oblique  backward  arid  outward,  to  the 
sterno-clavicular  articulation  ;  the  posterior  ligament  of  this  articula- 
tion is  weaker  than  the  anterior :  two  other  ligaments  are  there  seen, 
the  costo-clavicular  and  also  the  inter-clavicular,  which  is  extremely 
important,  as  it  extends  the  region  superiorly.  The  sternum  is  also 
united  on  the  outside  to  the  cartilage  of  the  true  ribs,  between  which 
it  is  as  it  were  suspended.  Its  articulations  are  compact;  but  few 
muscles  exist  in  this  region  and  none  of  them  belong  to  it  exclusively : 
the  two  pectoral  muscles  intercross  on  the  median  line  by  their 
aponeurosis,  the  sterno-mastoideus  above,  the  xyphoid  fasciculus  of  the 
rectus  abdominis  below :  posteriorly,  the  termination  of  the  triangu- 
laris  sterni  muscle.  The  arteries  arise  from  the  trunk  of  the  internal 
mammary  artery,  situated  on  the  outside  of  the  limits  of  the  region :  a 
small  twig  frequently  comes  from  the  neck,  passing  on  the  upper  groove 
of  the  sternum,  it  arises  from  the  inferior  thyroid  artery,  from  one  of 
21 


162  TOPOGRAPHICAL    ANATOMY. 

the  external  branches  of  the  subclavian  artery,  or  from  this  latter. 
The  veins  attend  the  arteries :  the  lymphatic  vessels  proceed  partly 
into  the  cervical  ganglions,  partly  into  those  of  the  axilla,  and  partly  into 
the  adjacent  internal  mammary  ganglions.  The  cellular  tissue  is  dense 
in  the  centre  and  but  little  exists  there  :  less  is  found  externally:  but 
little  fat  exists  in  this  point  where  the  skin  is  hairy  and  very  folliculary 
as  in  every  region  covered  with  hair. 

2.  Relations.  The  layers  of  this  region  are^  the  skin  which  is  at- 
tached on  the  median  line,  a  cellular  layer  which  is  not  fatty,  and  in 
which  the  tendons  of  the  stern o-mastoid  and  the  pectoral  muscles,  and 
some  fibres  of  the  rectus  abdominis  muscle,  are  situated ;  next  the  ster- 
num covered  posteriorly  with  a  dense  periosteum  and  with  some  fibres 
of  the  triangularis  sterni  muscle. 

Development.  In  the  fetus,  the  sternal  region  is  very  low  propor- 
tionally ;  it  increases  till-  the  period  of  puberty  in  the  male-:  in  the  fe- 
male, it  preserves  the  arrangement  of  infancy.  ' 

Varieties.  In  some  individuals,  this  region  is  elevated  in  the  centre, 
as  in  birds  :  this  arrangement  is  attended  with  a  transverse  contraction 
of  the  whole  chest ;  in  others  it  is  very  much  depressed  inferiorly : 
every  person,  in  whom  the  chest  serves  as  a  point  of  support  during 
labor,  is  singularly  disposed  to  this  affection,  which  is  presented  in  the 
greatest  degree  by  shoemakers,  especially 'when  they  begin  to  work 
early  in  life,  while  the  sternum  is  still  semi-cartilaginous.  In  this  re- 
gion we  sometimes  find  a  special  muscle  which  Meckel*  regards  as  the 
repetition  of  the  rectus  abdominis- muscle  ;  sometimes  it  unites  this  and 
the  sterno-mastoideus  :  sometimes  it  is  situated  out  of  this  region  ;  the 
sterno-mastoid  tendon  often  descends  very  low  to  the  rectus  muscle. 

Uses.  This,  region  is  suspended  between  the  regions  of  the  ribs  and 
the  .clavicle,  and  protects  by  its  resistance  the  deep  organs,  and  retreats 
before  injury.  Its  motions  are  sometimes  those  of  elevation  and  some- 
times of  depression  :  the  first  are  such  that  while  they  occur,  the  whole 
region  is  carried  forward,  and  particularly  downward  ;  it  seems  to  have 
a  vibratory  motion.  The  whole  shoulder  executes  on  the  upper  part 
of  the  region  motions  of  elevation,  confined  by  the  costo-clavicular 
ligaments,  and  of  depression  which  are  soon  arrested  by  meeting  the 
first  rib ;  its  motions  anteriorly  are  weak,  on  account  of  the  direct 
tension  of  the  posterior  muscles  of  the  shoulder,  but  much  more  ex- 
tensive posteriorly,  although  also  confined  at  last,  by  the -anterior 
muscles  of  the  shoulder:  finally,  this  sterno-clavicular  articulation 
admits  cf  a  motion  of  circumduction  composed  of  all  these. 

Pathological  and  operative  deductions.     We  not  unfrequently  find 

*  See  Doane's  Meckel,  vol.  2,  p.  99. 


DORSAL    REGION.  163 

this  region  to  oe  partially  or  entirely  cleft ;  the  internal  organs  are  then 
almost  naked ;  the  frequent  bifurcation  of  the  xyphoid  cartilage, 
as  also  the  foramen,  which  is  sometimes  seen  in  the  sternum,  must  be 
considered  as  the  least  possible  degree  of  this  conformation.  The  de- 
pression of  the  sternum,  if  very  much  marked,  as  in  shoemakers,  im- 
pedes the  motions  of  the  heart ;  the  posterior  curve  of  the  xyphoid 
appendage  cannot  impede  the  motions  of  the  stomach  as  has  been 
imagined  ;  and  this  also  has  been  considered  as  a  cause  of  gastralgia, 
only  by  ignorant  physicians,  who  are  incapable  of  forming  a  correct 
opinion  in  respect  to  the  true  cause  of  disease.  The  sternum,  on  ac- 
count of  its  spongy  nature  and  of  its  mobility,  cannot  be  broken  except 
by  a  violent  force.*  Luxation  of  the  clavicle  anteriorly  on  the  sternum 
is  explained  by  the  extensive  motions  of  the  shoulder  posteriorly,  and 
not  by  the  arrangement  of  the  anterior  ligament,  which  is  the  strongest ; 
in  this  luxation  the  head  of  the  clavicle  is  thrown  forward,  raising  the 
sterno-mastoid  tendon.  Wounds  of  this  region  are  not  very  serious, 
when  they  are  confined  to  it.  Venereal  tnmors  are  often  developed  in 
the  sternum,  on  account  of  its  superficial  situation.  Boyer  and 
Genouville  have  removed  a  great  part  of  the  sternum  for  an  affection 
of  caries,  which  often  appears  in  this  bone.  In  Boyer's  case,  the  in- 
ternal mammary  artery  was  divided,  because  this  surgeon  carried  his 
instrument  beyond  the  external  limits  of  the  region.  It  is  not  certain 
that  Galen  performed  this  operation.  Skieldrup  and  Laennec  have 
proposed  to  trepan  this  region  at  the  lower  part  in  order  to  puncture 
the  pericardium.  This  method  is  recommended,  as  the  signs  of  dropsy 
of  the  pericardium  are  very  uncertain  ;  by  this  mode  the  envelope  of 
the  heart  can  be  examined,  and  the  presence  of  the  liquid  may  be  as- 
certained before  it  is  opened.  Trepanning  also  is  indicated  to  remove 
a  circumscribed  caries  of  the  sternum,  and  to  evacuate  the  pus  from 
an  abscess  in  the  mediastinum.  This  operation  has  been  proposed  to 
facilitate  the  ligature  of  the  brachio-cephalic  trunk ;  we  shall  speak  of 
it  in  another  place. 


3.      DORSAL       REGION. 

The  dorsal  region,  a  portion  of  the  great,  spinal  region,  occupies 
specially  the  posterior  face  of  the  chest;  its  limits  are  exact :  it  is 
bounded  laterally  by  the  sacrospinalis  muscle,  above  by  the  second 
cervical  vertebra,  and  below  by  the  level  of  the  last  rib. 

*  Billard,  at  Brest,  has  performed  gastrotomy  to  raise  a  xyphoid  cartilage  which  was  broken 
and  pressed  down  to  the  stomach,  the  functions  of  which  were  deranged  by  it. 


* 

164  TOPOGRAPHICAL     ANATOMY. 

It  is  unmated  and  symmetrical,  elongated  and  curved  so  that  it  is 
convex  posteriorly  and  concave  anteriorly. ;  it  is  particularly  thick  in 
the  centre,  where  it  is  measured  by  the  distance  from  the  summit  of 
the  spinous  processes  to  the  anterior  part  of  the  bodies  of  the  vertebrae. 

The  dorsal  region  presents  two  faces,  one  on  which  the  median 
septum  of  the  chest  rests  ;  we  shall  speak  of  it  hereafter  :  the  other  is 
cutaneous,  arid  presents  on  the  median  line,  a  raphe,  which  is  depressed 
in  strong  and  well  formed  individuals,  but  is  prominent  in  those  of  an 
opposite  character :  laterally,  two  longitudinal  prominences,  which 
belong  to  the  sacrospinales  muscles. 

Structure.  —  I.  Elements.  The  skeleton  in  this  place  is  formed 
essentially  by  the  thoracic  portion  of  the  spine  :  the  vertebral  articu- 
lations of  the  ribs  are  also  situated  there.  Let  us  remember  that  the 
layers  of  the  vertebras  are  placed  upon  one  another,  and  entirely  cover 
the  yellow  ligaments :  that  the  vertebral  canal  is  narrow  and  cylin- 
drical, that  it  contains  the  medulla  which  terminates  at  its  lower  part, 
and  finally,  that  besides  the  curve  convex  posteriorly,  presented  by  the 
spine,  it  is  also  slightly  bent  to  the  left ;  the  dorsal  portion  of  the  sacro- 
spinalis  muscle,  which  occupies  each  side  of  this  region,  is  composed 
of  a  small  portion  of  the  sacro-lumbalis,  longissimus  dorsi,  transversalis 
colli,  the  lombo-dorsal  interspinales,  and  the  semi-spinalis  dorsi  mus- 
cles. The  small  supracostales  muscles  come  from  this  region,  where 
also  we  find  the  vertebral  origins  of  the  splenius,  the  two  complexi,  the 
serratus  posticus  minor,  the  rhomboideus,  the  trapezius,  and  the  lon- 
gissimus dorsi  muscles.  The  vertebral  aponeurosis  or  the  small  ser- 
rati  muscles,  belong  solely  to  this  part  of  the  body ;  we  must  mention 
also  its  resistance  and  its  attachments  to  the  spinous  processes  on 
the  inside,  to  the  angle  of  the  ribs  on  the  outside,  and  its  continuity 
above  and  below  with  the  two  serrati  muscles :  the  skin  is  thicker  than 
on  the  anterior  face  of  the  chest,  but  resembles  it  in  the  size  and 
abundance  of  its  follicles.  The  arteries  come  from  the  dorsal  branches 
of  the  intercostal  arteries,  which  belong  exclusively  to  this  region  and 
proceed  in  it  from  before  backward:  we  also  find  superiorly  some 
branches  of  the  deep  cervical  artery,  and  others  on  the  outside,  which 
come  from  the  transverse  cervical  or  the  posterior  scapular  artery,  the 
trunk  of  which  is  situated  in  the  scapular  region.  The  veins  attend 
the  arteries.*  The  superficial  lymphatic  vessels  go  partly  to  the  axil- 
lary and  partly  to  the  cervical  ganglions  :  the  deep  lymphatic  vessels 
generally  have  a  different  destination,  and  terminate  in  the  intercostal 

*  Godman  has  described  as  the  vena  azygos  dorsalis,  a  small  superficial  vein  situated  on 
the  median  line,  single  at  the  base  of  the  back  where  it  arises,  and  separated  above  into  two 
branches,  which  pass  through  the  trapezius  and  go  to  the  transverse  cervical  vein.  This 
vessel  is  very  constant. 


DORSAL  REGION.  165 

ganglions.  The  nerves  belong  to  the  posterior  branches  of  the  dorsal 
nerves  :  they  follow  the  course  of  the  arteries :  some  of  them  also  come 
from  the  cervical  plexus  and  from  the  spinal  nerve.  The  sub-cuta- 
neous cellular  tissue  is  very  dense,  especially  on  the  median  line  ;  but 
the  layer  it  forms  cannot  be  called  the  dorsal  aponeurosis.  We  find 
but  little  fat  on  the  outside,  and  little  or  none  between  the  muscles. 

2.  Relations.  The  relations  of  the  dorsal  region  are  very  simple  : 
we  find  there  a  first  layer  formed  by  the  skin  adhering  on  the  median 
line  to  the  summit  of  the  dorsal  spinous  processes,  which  are  covered 
with  the  supra-spinal  ligament ;  then  successively,  on  each  side,  we 
find  a  dense  adipose  cellular  layer,  in  which  the  dorsal  azygos  vein  of 
Godman  is  situated,  the  trapezius,  and  the  latissimus  dorsi,  which  the 
first  covers  in  one  point  only,  the  rhomboideus,  the  serratus  posticus 
inferior,  and  the  vertebral  aponeurosis  ;  the  splenius  only  above,  but 
in  every  other  part,  the  sacro-lumbalis,  the  longissimus  dorsi,  and  the 
dorsal  interspinales  muscles,  which  are  separated  by  two  interstices, 
through  which  emerge  the  branches  of  the  nerves  and  vessels  which 
are  distributed  in  the  more  superficial  layers  ;  above,  and  also,  on  the 
preceding  plane,  we  find  the  two  complexi  and  the  transversarius, 
which  are  situated  a  little  deeper  than  this  on  the  outside  ;  finally,  the 
supracostal  and  the  semi-spinalis  dorsi  muscles,  the  costo-transverse 
articulations,  then  the  inferior  costo-transverse  ligaments  are  exposed, 
and  also  the  foramen  formed  by  them  with  the  spine,  through  which 
pass  the  dorsal  nerves  and  vessels ;  finally,  we  perceive  the  layers  of 
the  vertebrae. 

Development.  The  development  of  this  region,  by  two  primitively 
distinct  lateral  portions,  is  proved  by  the  raphe :  in  the  fetus,  the  back 
presents  at  first  a  posterior  curve,  which  is  much  larger  than  in  the 
adult:  the  lateral  curve  is  deficient,  the  yellow  ligaments  are  not 
completely  concealed  by  the  vertebral  lamina? :  after  birth,  the  lateral 
curve  is  progressively  formed,  the  spine  becomes  straighter,  and  the 
yellow  ligaments  are  concealed,  as  we  have  seen.  In  the  old  manr 
the  region  resumes  the  characters  of  the  fetal  state,  especially  in  respect 
to  the  curves. 

Varieties.  In  some  individuals,  the  posterior  curve  of  this  region 
is  very  great :  this  is  true,  also,  of  the  lateral  curve,  in  individuals 
whose  professions  require  constant  efforts  of  the  right  upper  extremity, 
especially  to  raise  weights.  This  curve,  which  is  generally  convex 
to  the  left,  occurs  in  the  opposite  direction  in  left-handed  people. 
Beclard  has  availed  himself  of  this  fact,  to  support  Bichat's  opinion, 
tending-  to  show  the  lateral  inclination  of  the  spine  as  resulting  from 
its  necessary  flexion  when  we  raise  a  weight  with  one  arm.  This 
flexion  takes  place  towards  the  side  opposite  the  limb-  in  action. 


166  TOPOGRAPHICAL    ANATOMY. 

Farther,  the  absence  of  the  curve  in  children,  its  disappearance  in  old 
men,  its  slight  development  in  idlers,  its  great  development  in  porters, 
are  circumstances,  which,  with  the  facts  admitted  by  Beclard,  leave 
no  doubt  in  regard  to  the  mechanism  of  its  formation. 

Pathological  and  operative  deductions.  An  arrest  of  development 
is  followed  sometimes  with  a  complete,  and  sometimes  with  a  partial 
division  of  this  region,  as  in  spina  bifida;  our  remarks  on  lateral  curva- 
ture explain  why,  in  persons  affected  with  rachitis,  the  dorsal  curve  is 
most  generally  an  effect  of  the  normal  lateral  curve  :  .more  rarely,,  it 
results  from  an  increase  of  the  posterior  curve.  On  the  contrary,  in 
tabes  dorsalis,  which  acts  upon  the  skeleton  of  this  region,  and  which 
consists  in  a  tuberculous  change  of  the  bodies  of  the  vertebrae,  the 
flexion  which  constitutes  a  dorsal  curve  is  from  behind  forward.  In 
falls  on  the  back,  the  spinous  processes,  or  their  layers,  are  fractured 
by  a  counterblow  much  more  easily,  as  the  first  are  sab-cutaneous, 
and  as  the  region,  on  account  of  its  curve,  falls  more  on  the  soil  than 
•the  rest  of  the  posterior  face  of  the -trunk:  we  will  remark,  however, 
that  the  imbricated  arrangement  of  the  spinous  processes  protects  them 
from  the  action  of  external  violence,  as  does  also  the  posterior  curve  of  the 
libs,  which  passes  beyond  their  plane,  and  which,  in  falls,  consequently 
conies  first  to  the  ground.  Wounds  of  this  region  cannot  cause  a  dan- 
gerous hemorrhage  :  a  sharp  instrument  is  less  liable  to  injure  the 
medulla  in  the  adult  than  in  the  child:  when  it  penetrates  deeply 
in  the  adult,  it  is  difficult  to  touch  the  medulla  until  it  has  passed 
through  the  layers  of  the  vertebrae  ;  in  the  second,  their  slight  degree 
cf  imbrication  produces  an  opposite  effect.  Some  purulent  tumors 
often  appear  in  this  region :  if  the  pus  be  formed  under  the  skin,  it 
never  points  between  the  muscles,  on  account  of  the  compact  nature 
of  the  cellular  tissue  of  this  part ;  it  tends  very  much  to  go  downward, 
especially  if  it  be  placed  under  the  vertebral  aponeurosis,  which  pre- 
vents it  from  going  towards  the  skin :  hence  the  precept,  to  open  deep 
abscesses  early,  if  they  are  not  caused  by  caries  of  the  spine,  and  the 
slight  inconvenience  in  waiting  for  superficial  abscesses.  Tumors 
formed  by  the  development  of  the  internal  organs  may  raise  the  layers 
of  the  dorsal  region :  we  shall  speak  of  them  separately. 


4.  .    DIAPHRAGMATIC      REGION. 

The  inferior  wall  of  the  chest  is  situated  deeply  from  the  skin  i  it 
forms  one  great  region,  termed  the  diaphragmatic. 

The  diaphragmatic  region  is  not  complicated,  but'  very  important : 
its  extent  cannot  be  determined  externally  :  it  is  included,  as  it  were, 


DIAPHRAGMATIC  REGION.  167 

in  the  area  of  the  base  of  the  thorax,  which  serves  as  its  limits  :  but  it 
rises  a  certain  height  on  the  inside  of  it,  which  arrangement  diminishes 
the  cavity  of  the  chest,  and  increases  that  of  the  belly.  The  thickness 
of  this  region  is  uniform  in  every  partj  and  is  about  four  lines ;  it 
descends  lower  posteriorly  and  on  the  sides,  than  anteriorly ;  its 
direction,  also,  is  oblique  downward,  forward,  and  a  little  to  the  right, 
like  the  base  of  the  thorax >  which  receives  it. 

In  this  region,  we  distinguish  two  faces  and  a  circumference  ;  the 
upper  face,  which  is  serous  and  convex,  looks  backward,  upward, 
and  on  the  sides,  thus  establishing  its  relations  with  the  dorsal,  lumbar, 
and  costal  regions,  from  which  it  is  separated  only  by  a  sinuous  pro- 
longation of  each  pulmonary  cavity,  into  which  prolongation  the  lungs 
penetrate  during  inspiration.  In  the  centre;  this  face  is  united  to  the 
mediastinum  and  the  pericardium,  and  its  most  convex  part  ascends 
to  the  level  of  the  eighth  dorsal  vertebra :  on  the  sides,  it  is  loose,  and 
some  lines  higher,  on  account  of  the  general  direction  of  the  region, 
a  direction  imparted,  particularly  on  the  right,  by  that  of  its  bony 
circle,  and  also  by  the  liver,  which  presses  it  on  this  side.  The  lower 
serous  face,  also,  which  is  concave,  looks  forward,  down  ward;  and 
inward  :  it  is  attached  to  the  liver  and  stomach  by  cellular  substance, 
or  serous  folds.  The  circumference  is  very  much  elevated  anteriorly ; 
it  is  united  to  the  sternal  region  near  its  lower  extremity,  and  forms 
with  it  a  triangular  space,,  through  which  the  cellular  tissue  of  the 
mediastinum  communicates  with  that  of  the  abdominal  wall  at  the 
pit  of  the  stomach :  it  adheres  to  the  costal  region  on  the  sides,  where 
this  circumference  descends  on  the  inside  to  near  the  level  of  the 
cartilaginous  edge  of  the  false  ribs :  finally,  at  the  posterior  part,  it 
descends  still  lower,  before  the  upper  part  of  the  lumbar  region,  with 
which  it  is  united,  and  forms,  first,  an  oblique  median  opening,  the 
aortic  passage,  through  which  the  aorta,  the  thoracic  canal,  and  the 
azygos  vein  pass :  second,  two  other  lateral  openings,  surrounded  by 
fibrous  arches  ;  one  of  these  encloses  the  upper  extremity  of  the  psoas, 
the  two  tri-splanchnic  nerves,  and  the  great  sympathetic  nerve  ;  the 
other  contains  the  last  intercostal  vessels  and  nerves.  Through  this 
region,  the  vena  cava  and  the  esophagus  pass  :  for  the  former,  there 
is  a  quadrilateral  fibrous  opening ;  and  for  the  second,  an  opening 
which  is  fibrous  above,  and  fleshy  below  and  on  the  sides. 

Structure.  —  1.  .Elements.  This  region  is  formed  essentially  by 
the  diaphragm,  which  is  tendinous  in  the  centre,  and  fleshy  at  the 
circumference,  to  which  the  two  pleurae  and  the  serous  layer  of  the 
pericardium  contribute  above,  and  the  peritoneum  below,  and  also  a 
compact  cellular  tissue,  free  from  fat.  The  arteries  come  from  the 
internal  mammary  artery  and  the  aorta,  by  the  superior  and  inferior 


163  TOPOGRAPHICAL  ANATOMY. 

diaphragmatic  arteries :  some  also  come  from  the  last  intercostal  arte- 
ries :  the  veins  and  the  lymphatic  vessels  follow  the  same  direction. 
The  nerves  are  twigs  of  the  cerebro-spinal  system,  and  are  particularly, 
the  two  phrenic  nerves,  branches  of  the  cervical  plexus,  and  some 
filaments  of  the  last  intercostal  nerves.  Some  branches  proceed,  also, 
from  the  great  sympathetic  nerve,  by  means  of  the  inferior  diaphragm- 
atic plexuses,  the  smallest,  divisions  of  the  solar  plexus. 

2.  Relations.  The  special  relations  are  extremely  simple,  and  need 
hardly  be  mentioned :  on  the  sides,  the  pleura,  the  fleshy  portion  of  the 
diaphragm,  and  the  peritoneum :  in  the  centre,  the  serous  membrane 
of  the  pericardium,  the  tendinous  portion  of  the  diaphragm,  and  the 
peritoneum. 

Development.  The  sides  of  this  region  are  doubtless  formed  first, 
and  it  is  completed  by  their  union  in  the  centre  :  it  is  said,  that  at  first,  it 
does  not  exist,  and  that  then  the  abdomen  and  thorax  are  united,  and 
form  one  great  splanchnic  cavity,  similar  to  that  of  birds,  reptiles,  and 
fishes. 

Varieties.  This  region  is. a  little  more  convex  in  the  female  than 
in  the  male  ;  and  more  so  in  those  who  have  borne  many  children. 

Uses.  The  resistance  of  the  diaphragmatic  region  is  very  great  in 
the  centre,  on  account  of  its  aponeurotic  structure,  and  because  its 
fibres  interlace  there  in  every  direction ;  ruptures  of  it  occur  solely  on 
the  sides,  where  the  fleshy  fasciculi  are  loose  and  easily  separated. 
The  whole  of  this  region  executes  motions,  by  which  its  directions  and 
positions  are  singularly  varied.  These  motions  are  greatest  in  the 
sides,  the  centre  being  kept  in  place  by  its  median  adhesion  :  sometimes 
the  entire  region  is  depressed,  and  sometimes  elevated,  as  in  respiration  ; 
sometimes  its  surface  is  diminished  by  the  contraction  of  its  osseo- 
cartilaginous  frame.  When  this  is  depressed  quickly,  it  imparts  to 
the  abdominal  viscera  an  impulse,  which  extends  to  the  right  buttock 
if  the  anterior  abdominal  wall  be  relaxed ;  but  this  latter  receives  the 
impulse,  when  it  is  contracted  spasmodically,  as  in  vomiting ;  then, 
in  fact,  the  anterior  abdominal  wall  forms  a  plane  turned  backward 
and  upward,  opposite  in  every  respect  to  that  of  the  diaphragm,  and 
the  stomach  is  pressed  violently  between  the  two  regions. 

Pathological  and  operative  deductions.  This  region  may  be  par- 
tially or  entirely  deficient :  we  have  seen  a  fetus  in  whom  only  the  car- 
diac region  existed.  Before  arriving  at  this  region  a  wounding  instru- 
ment must  first  pass  through  the  costal,  lumbar,  dorsal,  or  costo-iliac 
regions ;  the  diaphragmatic  region  can  be  aifected  only  by  blows, 
which  act  obliquely  on  the  latter,  from  below  upward.  Farther,  in  a 
pregnant  woman,  during  a  full  expiration,  a  wounding  instrument,  car- 
ried horizontally  very  high  on  the  costal  region,  may  reach  the  lower 


UPPER  WALL  OF  THE  THORAX.  169 

wall  of  the  chest,  which  in  opposite  circumstances  being  very  much 
depressed,  might  be  uninjured  by  the  same  instrument.  We  will  say 
also,  that  an  instrument  which  touches  this  region,  if  it  acts  on  the  ma- 
thematical line  represented  by  its  circumference,  must  penetrate  into 
the  abdomen  or  the  chest ;  it  might  even  be  introduced  into  both,  either 
first  passing  into  the  former  cavity,  or,  on  the  contrary,  acting  prima- 
rily on  the  second.  In  violent  exertions,  or  in  falls  from  a  lofty  place, 
the  diaphragmatic  region  is  sometimes  lacerated  on  the  right  or  left, 
more  frequently  on  the  left,  doubtless  because  this  side  is  less  support- 
ed :  hence  the  hernias  termed  diaphragmatic,  in  which  the  floating 
viscera  of  the  abdomen  go  upward  into  the  thorax :  this  occurs 
more  easilyj  because  in  inspiration  the  diaphragmatic  region  is  depress- 
ed towards  them.  We  saw  in  the  Hospital  la  Charite,  in  1 820,  a  stran- 
gulated diaphragmatic  hernia  of  the  stomach.  Diaphragmatic  hernias 
may  also  occur  through  the  infrasternal  space.  They  may  be  fatty. 
In  ulcerations  by  a  pulpy  softening  of  the  stomach,  termed  sponta- 
neous ulcerations,  this  region  is  sometimes  perforated  entirely  ;  we  have 
seen  several  instances  of  this,  and  it  has  been  said  in  these  cases,  that 
a  corrosive  liquid  from  the  stomach  had  acted  upon  it.  .  When  speak- 
ing of  the  costal  region,  We  mentioned  the  sympathy  between  this  and 
the  diaphragmatic  region.  When  the  pleura  or  the  diaphragmatic 
peritoneum  are  inflamed,  severe  pains  are  felt,  and  extend  towards  the 
neck  arid  the  top  of  the  shoulder ;  the  diaphragmatic  nerve,  the  origin 
and  termination  of  which  correspond  to  these  points,  explains  this  phe- 
nomenon. .Most  physicians  consider  inflammation  of  the  diaphragm 
as  constantly  manifested  externally  by  the  Sardonic  laugh  ;  this  affec- 
tion always  affects  respiration  in  a  great  degree,  as  the  diaphragm  is  the 
principal  agent  of  it.  Farther,  in  inflammations  of  the  region  of  the 
diaphragm,  the  base  of  the  chest  is  selected  for  the  application  of  leeches 
and  for  counterirritation,  where  the  intercostal  vessels  and  nerves  ramify 
partly  in  the  skin,  and  send  some  filaments  also  towards  the  circum- 
ference of  the  diaphragm.  We  shall  not  mention  here  those  cartila- 
ginous or  osseous  diaphragms  found  by  authors:  they  have  mistaken 
as  such  incrustations  of  the  pleura,  or  peritoneum,  whether  situated  in 
its  loose  surface  or  formed  on  the  attached  portion  of  these  membranes. 


5.    UPPER      WALLOP      THE      THORAX. 

This  wail,  situated  at  the  union  of  the  thorax  and  tracheal  portion 

of  the  neck,  corresponds  in  the  centre  to  the  laryiigo-tracheal  region, 

and  on  the  sides  to  the  supra-clavicular  and  carotid  regions.     The 

most  general  remarks  are,  that  it  is  constituted  by  all  the  organs  which 

22 


170  TOPOGRAPHICAL   ANATOMY. 

are  comprehended  in  the  area  of  a  circle,  formed  by  the  sternum  ante- 
riorly, the  spine  posteriorly,  by  the  first  rib  and  its  cartilage  laterally 
and  on  each  side.  It  would  be  useless  to  enter  into  farther  details, 
which  would  expose  us  to  repetitions  ;  we  should  also  anticipate  our  re- 
marks in  respect  to  the  mediastinum  and  the  pulmonary  cavities. 

We  observe,  however,  in  conclusion,  the  providence  of  nature  in 
arranging  the  upper  part  of  the  thorax:  she  has  rendered  its  circumfe- 
rence immoveable  by  forming  it  of  bones ;  and  hence,  by  freeing  the 
important  organs  which  it  contains  from  all  compression,  she  has 
insured  the  integrity  of  their  functions. 


ARTICLE    II. 


CAVITY       OF       THE       CHEST. 

The  cavity  of  the  chest  is  not  single,  although  it  is  generally  men- 
tioned as  such,  but  it  presents  this  arrangement  only  in  the  skeleton. 
In  the  recent  state,  this  portion  of  the  trunk  is  divided  into  two  dis- 
tinct cavities,  in  which  are  situated  the  lungs ;  hence  these  cavities  are 
called  the  pulmonary  cavities.  We  have  studied  the  different  regions 
which  form  the  external  circumference  of  the  chest ;  we  have  now  to 
examine  that  which  separates  them,  the  mediastinum.  We  shall  then 
study  the  pulmonary  cavities. 


PARAGRAPH       FIRST. 


MED1AST1NAL    REGION. 


This  region  is  not  visible  externally ;  its  limits  are  nevertheless  exact ; 
it  is  continued  to  the  skin  by  the  sternal  region  anteriorly,  by  the  dorsal 
region  posteriorly,  and  it  terminates  below  in  the  inferior  wall  of  the 
thorax,  and  above  near  the  superior. 

The  direction  of  the  mediastinum  is  oblique  downward,  and  to  the 
left ;  to  observe  it,  we  must  examine  this  region  only  in  the  centre  of 
its  faces,  and  especially  on  the  left.  Its  direction,  posteriorly  and  ante- 
riorly, directly  under  the  sternum,  is  that  of  the  median  line.  This  con- 
sideration is  highly  important,  as  we  shall  see  hereafter. 


MEDIASTINAL  REGION.  171 

The  height  of  the  mediastinum  varies  ;  its  antero-posterior  diameter 
is  equal  to  the  distance  from  the  sternum  to  the  spine ;  its  breadth  is 
considerable  below  and  also  above  ;  in  the  centre,  this  region  is  nar- 
rower than  in  any  other  part ;  hence  it  has  been  compared  to  an  X. 

This  region  presents  two  smooth  lateral  faces,  and  gives  inser- 
tion, at  the  root  of  the  lung,  to  the  union  of  their  posterior  third 
with  the  two  anterior  thirds.  The  left  face  is  convex  downward  and 
in  the  centre,  it  also  varies  a  little  from  this  side ;  the  right  face  is 
concave  in  the  same  point. 

Structure. — 1.  Elements.  Most  of  the  organs  of  the  mediastinum 
only  pass  through  it,  and  others  terminate  in  it,  but  do  not  arise  there ; 
finally,  others  arise  in  it  and  go  elsewhere  ;  very  few  belong  entirely 
to  this  region  ;  the  principal  elements  of  this  region  are  the  heart  and 
its  envelope,  the  vessels  which  come  to  it,  those  which  depart  from  it, 
the  esophagosal  portion  of  the  alimentary  canal,  the  termination  of  the 
trachea  and  the  origin  of  the  bronchi,  the  vena  azygos,  the  thoracic 
canal  and  many  lymphatic  ganglions  which  receive  the  lymphatic 
vessels  from  the  organs  of  this  point,  the  par  vagum  and  the  cardiac 
nerves,  the  thoracic  portion  of  the  tri-splanchnic  nerve,  the  superior 
diaphragmatic  nerves  and  vessels,  with  a  layer  of  each  pleura :  we  also 
find  in  it  a  very  loose  cellular  and  adipose  tissue,  some  mediastinal 
vessels,  and  some  others  which  belong  to  the  different  organs  men- 
tioned, especially  to  the  bronchi,  the  esophagus,  the  pericardium,  and 
the  aorta. 

2.  Relations.  The  relations  examined  from  before  backward  are 
very  complex,  on  account  of  the  great  number  of  the  organs  ;  hence  to 
study  them  we  shall  divide  the  mediastinum  into  two  portions,  the  car- 
diac and  the  supra-cardiac. 

In  the  cardiac,  the  following  layers  successively  appear  behind  the 
lower  half  of  the  sternal  region ;  first,  a  loose  cellular  and  adipose 
layer  ;  second,  the  anterior  part  of  the  pericardium  ;*  third,  the  heart, 
from  which  the  large  arteries  arise,  and  in  which  the  vena  cava  ter- 
minates ;  if  we  analyze  the  elements  of  this  layer  more  particularly, 
we  find  there ;  anteriorly,  the  right  ventricle,  the  pulmonary  artery, 
the  right  auricle ;  more  deeply,  the  oblique  septum  of  the  ventricles  ;  still 
more  deeply,  the  left  ventricle,  the  aorta  which  conceals  the  pulmo- 
nary artery,  the  left  auricular  appendix,  the  right  auricle,  and  the 
superior  vena  cava  ;  finally,  the  left  auricle  and  its  veins.  These  are 
the  parts  in  the  pericardium  through  which  an  instrument  would  pass, 

*  On  account  of  the  convexity  of  the  left  lateral  face  of  the  mediastinum,  which  is  crowded 
back  by  the  heart,  the  left  pleura  slightly  covers  the  pericardium  anteriorly,  and  this  is  thus 
connected  with  the  left  costal  region. 


178  TOPOGRAPHICAL    ANATOMY. 

if  introduced  directly  from  before  backward,  and  this  also  is  the  order 
in  which  the  parts  would  be'  injured :  fourth,  in  this  cardiac  portion 
of  the  mediastinum,  but  more  deeply,  the  posterior  part  of  the  pericar- 
dium ;  fifth,  many  ganglions,  the  esophagus,  situated  on  the  median 
line,  having  on  its  edges  the  esophagoeal  cords  of  the  pneumo-gastric 
nerves ;  sixth,  the  aorta  on  the  left,  the  azygos  vein  on  the  right,  the 
thoracic  canal  in  the  centre ;  seventh,  a  loose  cellulo-fatty  layer,  in 
which  the  splanchnic  nerves,  the  intercostal  arteries  and  veins,  ramify ; 
eighth,  the  spine, 

In  the  supra-cardiac,  behind  the  upper  half  of  the  sternal  region,  we  find 
successively  from  before  backward  ;  first,  a  loose  cellule-fatty  layer,  in 
which  some  ramuscules  of  the  internal  mammary  artery  are  situated  ; 
second,  below,  a  prolongation  of  the  pericardium,  superiorly,  the  left  sub- 
clavianvein,whichis  directed  obliquely  down  ward  and  to  the  right;  third, 
a  plane  which  first  looks  forward,  then  inclines  to  the  right  and  left  to 
turn  around  the  bronchi,  and  is  formed  in  its  first  portion  by  the  aorta, 
the  brachio -cephalic  trunk,  and  the  superior  vena  cava ;  the  left  oblique 
portion  of  this  plane  is  formed  by  the  end  of  the  pulmonary  artery,  the 
arterial  ligament,  by  the  arch  of  the  aorta  which  turns  below  and  be- 
hind the  recurrent  nerve,  by  the  left  subclavian  and  carotid  arteries,  on 
the  outside  of  which  glide  the  left  par  vagum  and  phrenic  nerves, 
which  are  at  first  contiguous  but  are  then  separated  inferiorly ;  finally,  the 
right  oblique  portion  of  this  layer  is  formed  by  the  terminating  curve 
of  the  azygos  vein,  which  resembles  the  arch  of  the  aorta  in  many 
respects ;  on  the  outside  of  this  curve,  the  par  vagurn  and  phrenic 
nerves  glide,  as  on  the  left :  fourth,  we  find  above  and  on  the  median 
line,  the  end  of  the  trachea,  on  the  left  of  which  is  situated  the  left 
recurrent  nerve  ;  below,  a  rhomboid,  circumscribed  by  the  bronchi  and 
the  two  branches  of  the  pulmonary  artery  and  filled  with  lymphatic 
ganglions;  fifth,  the  esophagus,  which  curves  to  the  left  and  is  situ- 
ated behind  the  left  bronchus ;  sixth,  the  aorta,  the  azygos  vein,  arid 
the  thoracic  canal  between  them;  seventh,  a  loose  cellular  tissue,  in 
which  the  superior  intercostal  vessels  and  some  filaments  of  the  tri- 
splanchnic  nerve  ramify  ;  eighth,  the  end  of  the  longus  colli  muscles  ; 
ninth,  the  spine.  The  loose  and  abundant  cellular  tissue,  which  con- 
nects all  the  organs  of  the  mediastinum,  communicates  very  readily 
above  with  that  of  the  neck,  under  the  cervical  aponeurosis,  and  below 
with  that  of  the.  abdomen,  in  two  points  :  first,  before  the  .vertebral 
column,  through,  the  aortic  opening:  second,  anteriorly,  through  the 
substernal  triangular  space  of  the  diaphragmatic  region. 

Before  arriving  at  all  these  organs,  in  penetrating  through  the 
lateral  face  of  the  mediastinum,  we  come  to  the  .pleura,  which  is  inti- 
mately united  to  them  .inferiorly  by  a  cellular  tissue,  in  which  are 


MEDIASTINAL  REGION.  173 

found ;  the  diaphragmatic  vessels  and  nerves,  which  are  a  little  longer 
on  the  left  on  account  of  the  convexity  of  this  face  of  the  mediastinum, 
to  which  they  are  near  ;  these  vessels  and  nerves  are.  directed  obliquely 
downward  and  backward,  and  consequently  are  superficial  at  the  upper 
part  and  deep  seated  at  the  lower  ;  they  are  deeper  on  the  left  than  on 
the  right,  and  pass  before  the  root  of  the  lung  which  separates  them 
from  the  par  vagum.  The  root  of  the  liing  leaves  the  mediastinum 
nearer  its  upper  and  posterior  edges,  than  those  which  are  opposite  ; 
it  is  formed  from  before  backward  ;  first,  by  the  pulmonary  veins ; 
second,  by  the  pulmonary  artery  ;  third,  by  the  bronchus,  surrounded 
by  lymphatic  vessels  and  ganglions,  having  before  it  the  anterior  pul- 
monary plexus,  formed  by  some  filaments  of  the  pneumogastric  nerve 
and  of  the  cardiac  plexus,  and  behind  it,  the  par  vagum  nerve  and  the 
posterior  pulmonary  plexus.  Finally,  we  remark,  that  the  root  of  the 
lung  separates  on  each  side  the  phrenic  and  par  vagum  nerves,'  and  it 
serves,  in  its  narrow  portion,  for  the  limits  of  the  anterior  and  posterior 
mediastina  of  authors ;  a  divisioa  which  is  objectionable,  because  it 
cannot  be  traced  with  exactness. 

Development.  The  mediastinum  presents  at  first  in  the  fetus  no 
lateral  deviation,  the  heart  itself  being  situated  entirely  on  the  median 
line  ;  its*deviation  does  not  appear  until  the  third  month  of  fetal  exist- 
ence ;  in  the  early  periods,  and  even  after  birth,  the  mediastinum  con- 
tains the  thymus  gland, -which  forms  its  first  layer  under  the  sternal 
region  ;  this  layer  is  at  first  general,  but  afterwards  retreats  to  its  up- 
per part.  This  organ  is  entirely  wasted  after  birth ;  and  in  the  adult, 
its  place,  as  we  have  seen,  is  occupied  only  by  a  cellulo-adipose  layer  • 
there  is  no  fat  in  this  region  in  the  fetus,  and  but  little  in  the  child  ;  a 
moderate  quantity  of  it  in  the  adult,  while  it  exists  in  great  quantity 
in  old  age. 

Varieties.  The  mediastinum  is  convex  on  the  right,  where  the 
viscera  are  transposed,  or  even  where  there  is  a  mal-position  of  the 
heart.  In  the. first  case,  all  the  organs  of  the  mediastinum,  which  are 
usually  found  on  the  left  side,  are  situated  on  the  right,  and  vice  versa. 
Sometimes  supernumerary  arteries  leave  this  region,  on  the  plane  of 
the  arch  of  the  aorta,  and  go  to  the  neck ;  they  are  the  inferior  thyroid 
or  the  vertebral  artery.  The  numerous  varieties  of  the  aorta  and  the 
arteries  which  come  from  it,  so  well  described  by  Meckel  and  Tiede- 
mann,  present  no  modification  in  the  relations  of.  this  region  ;  some, 
however,  are  exceptions  to  this.  We  shall  mention  particularly  the 
alternate  bifurcation  and  union  of  the  aorta,  which  thus  circumscribes 
by  its  branches  a  circle,  in  which  the  trachea  and  esophagus -are  situ- 
ated ;  and  another  variety,  in  which  the  aorta  divides  near  its  origin 
into  two  branches,  each  of  which,  as  in  reptiles,  turns  around  the  cor- 


174  TOPOGRAPHICAL    ANATOMY. 

responding  bronchus  in  the  form  of  an  arch,  and  then  unite  behind  the 
heart  in  a  single  trunk.  The  mediastinum  is  lower  in  females ;  its 
height  also  is  considerably  diminished  during  pregnancy. 

Pathological  and  operative  deductions.  It  has  been  said  that  this 
region  may  be  entirely  deficient.  Cruveilhier  has  seen  a  fetus,  where 
one  of  its  pleural  layers,  the  left,  did  not  exist ;  the  heart  was  loose  in 
its  corresponding  pulmonary  cavity.  Breschet  has  mentioned  a  similar 
case  in  the  first  number  of  his  Repertoire  d?  Anatomic  Pathologique. 
In  those  cases  where  the  sternal  region  is  divided,  that  of  the  medias- 
tinum is  exposed ;  the  same  result  is  produced  artificially  by  the  re- 
moval of  a  portion  of  the  sternum.  Wounds  of  this  region  are  serious, 
as  may  be  seen  from  the  important  functions  of  the  parts  contained  in 
it ;  it  is  so  filled  with  vascular  organs,  that  its  lesions  are  generally 
fatal,  from  the  hemorrhage  they  cause.  A  wounding  instrument, 
which  acts  horizontally  from  before  backward,  cannot  reach  the 
mediastinum,  until  after  passing  through  the  sternal  region,  except 
on  the  left  side  and  inferiorly,  where  the  mediastinum  is  in  relation 
with  the  costal  region,  which  must  previously  be  perforated  below : 
the  relations  mentioned  demonstrate  sufficiently  that  if  the  instruments 
have  not  penetrated  deeply,  the  pericardium  alone  may  be  opened,  or 
with  it  the  right  cavities  of  the  heart  and  the  pulmonary  artery,  while 
more  deeply  the  left  cavities  and  the  aorta  may  be  interested :  the 
parietes  of  the  ventricles  are  so  thick  that  they  may  be  wounded, 
although  their  cavity  is  not  opened,  as  has  been  observed.  The  left 
cavities  of  the  heart,  and  the  other  organs  which  are  situated  deeply 
in  the  mediastinum,  may  be  injured  at  first,  if  the  wounding  instru- 
ment acts  from  without  inward  ;  the  wound  must  be  very  deep  to 
affect  the  esophagus.  The  left  lateral  prominence  of  the  mediastinum, 
and  particularly  that  of  the  heart  and  its  envelope,  has  suggested  to 
surgeons  the  idea  of  puncturing  the  pericardium  when  filled  with 
serum.  This  operation  was  proposed  by  Senac,  arid  performed  by 
Desault.  Senac  advises  to  operate  on  the  third  intercostal  space,  two 
fingers'  breadth  from  the  sternum,  directing  the  trocar  obliquely 
downward.  In  this  operation,  we  avoid  injuring  the  internal  mam- 
mary artery  and  its  branches,  but  the  pleura  is  opened.  The  heart, 
also,  may  be  injured,  and  the  patient  immediately  destroyed.  Skiel- 
drup  and  Laennec  have  proposed  to  trepan  the  sternum  at  the  lower 
part,  and  to  qpen  the  pericardium,  when  a  liquid  is  felt  in  its  cavity. 
The  same  mode  is  proper  for  opening  superficial  abscesses  of  the  medias- 
tinum, the  pus  from  which,  by  continuing,  might  disunite  the  elements. 
Abscesses  of  the  mediastinum  have  sometimes  pointed  at  the  abdominal 
wall,  near  the  pit  of  the  stomach,  after  dilating  the  substernal  opening 
of  the  diaphragm.  We  have  seen  one  case  of  this  kind.  These  ab- 


MEDIASTINAL  REGION.  175 

scesses  may  be  formed  by  the  pus  coming  from  the  cervical  region  ; 
our  remarks  on  this  region  demonstrate,  however,  that  those  which 
terminate  in  this  manner  are  situated  under  the  cervical  aponeurosis. 
Caries  of  the  bodies  of  the  dorsal  vertebrae  may  give  rise  to  congested 
abscesses,  which  fuse  under  the  aorta,  in  the  very  loose  cellular  tissue 
which  surrounds  it,  and  proceed  into  the  abdomen  through  the  aortic 
opening  of  the  diaphragm.  The  bronchial  or  esophagoeal  ganglions 
frequently  tumefy,  and  in  most  cases  from  sympathy ;  they  then 
compress  the  esophagus,  and  cause  dysphagia,  or  they  flatten  the 
trachea,  and  hinder  respiration ;  or  after  producing  these  symptoms, 
they  form  abscesses,  and  open  into  the  esophagus,  into  the  left  bronchus, 
or  into  both.  The  aorta  may  be  affected  with  aneurisms  at  its  origin, 
or  at  its  descending  portion  ;  when  developed  in  its  ascending  portion, 
they  go  particularly  toward  the  sternum,  which  they  destroy,  in  order 
to  open  externally :  sometimes  they  open  into  the  mediastinal  region  : 
these  tumors  compress  the  trachea  posteriorly,  into  which  they  open, 
or  they  are  developed  laterally  toward  the  lungs,  which  sometimes 
collapse  when  pressed  against  the  ribs.  The  aneurisms  which  are 
formed  at  the  arch  of  the  aorta  may  also  affect  the  sternal  region, 
contract  the  esophagus  and  trachea,  into  which  they  sometimes  open 
posteriorly :  below,  they  act  on  the  root  of  the  left  lung  ;  above,  they 
may  be  developed  toward  the  neck.  The  recurrent  nerve  is  generally 
very  much  compressed  in  aneurisms  of  the  arch  of  the  aorta,  especially 
in  those  which  are  developed  inferiorly  and  posteriorly ;  this  fact  has 
appeared  sufficient  to  some  writers,  and  particularly  to  Bourdon,  ta 
account  for  the  aphonia  which  so  often  attends  these  tumors,  which, 
however,  is  better  explained  by  their  compressing  the  trachea.  Aneu- 
risms of  the  mediastinal  descending  aorta,  by  being  developed  anteri- 
orly, compress  the  esophagus,  and  crowd  back  the  heart,  so  as  to  lead 
to  the  suspicion,  as  we  have  seen,  of  an  affection  of  this  organ  ;  farther, 
this  error  is  much  more  easy,  inasmuch  as  double  pulsations  are  felt 
by  the  patient  much  stronger  and  more  superficial  than  usual.  These 
tumors  destroy  the  vertebral  column  on  the  left,  and  it  is  worthy  of 
remark,  that  here,  as  in  all  other  points,  the  bones  yield  much  more 
promptly  than  the  intervertebral  fibro- cartilages ;  doubtless  because 
these  latter,  from  their  elasticity,  bend  under  the  pulsations :  finally, 
they  also  may,  however,  be  destroyed.  We  have  seen  an  individual 
affected  with  so  large  an  aneurism  of  the  descending  thoracic  aorta, 
and  one  of  so  long  standing,  that  it  had  projected  into  the  left  pulmo- 
nary cavity,  and  crowded  back  the  lung,  had  destroyed  the  posterior 
extremity  of  the  ribs,  and  pulsated  in  the  dorsal  region,  which  was 
raised  by  it.  From  the  influence  of  causes  but  slightly  understood, 
the  esophagus  sometimes  undergoes  a  change,  which  is  at  first  pulpy. 


176  TOPOGRAPHICAL  ANATOMY. 

and  afterwards  it  is  completely  destroyed ;  this  seems  of  the  same 
nature  as  the  alteration  of  the  stomach  which  precedes  spontaneous 
perforations  of  this  viscus.  We  have  seen  it  twice  in  patients  who 
died  from  other  diseases ;  farther,  in  one  of  them,  the  esophagus  was 
destroyed  the  whole  length  of  the  mediastinum,  which  represented  an 
enormous  sac,  distended  by  the  drinks  swallowed  by  the  patient  before 
his,  death. 


PULMONARY      CAVITIES. 

Each  side  of  the  thorax  presents  a  cavity,  termed  the  pulmonary, 
because  it  receives  the  lung.  Its  parietes  are  formed  externally  by  the 
costal  region :  the  sternal  and  dorsal  regions,  which  are  continuous 
with  the  mediastinum,  separate  these  two  cavities.  The  form  of  the 
pulmonary  cavity  is  that  of  the  lung,  which  it  exactly  contains.  A  body 
moulded  upon  it  would  be  convex  on  the  outside,  flattened  internally, 
and  slightly  concave  below  and  to  the  left ;  it  is  rounded  above^  and 
received  in  a  sort  of  cul-de-sac,  which  rises  above  the  first  rib ;  its 
lower  part  is  concave  in  the  centre,  and  would  terminate  on  the  outside 
by  a  very  depressed  cutting  edge,  and  would  be  received  in  a  narrow 
simls,  formed,  as  has  been  said,  by  the  union  of  the  costal  and  dia- 
phragmatic parietes,  the  costo-diaphragmatic  sinus.  The  vertical 
extent  of  this  cavity  generally  varies,  like  the  position  of  the  dia- 
phragmatic region  in  respiration ;  these  variations,  however,  occur 
only  in  the  centre ;  near  the  ribs,  the  cavity  is  always  bounded  below 
by  the  invariable  attachments  of  the  diaphragm,  on  which  the  pleura 
is  reflected.  The  vertical  diameter  is  less  on  the  right  than  on  the 
left  side;  the  transverse  diameter  presents  an  opposite  arrangement ; 
on  the  left,  it  is  more  extensive  posteriorly  than  anteriorly,  on  account 
of  the  lateral  curve  of  the  spine  and  the  deviation  of  the  mediastinum ; 
on  the  right,  we  find  an  opposite  arrangement,  for,  opposite  reasons ; 
generally  considered,  the  right  pulmonary  cavity  is  larger  than  the 
left  in  the  normal  state.  The  lungs,  which  are  contained  in  the  pul- 
monary cavities,  must  not  be  described  here ;  they  belong  to  descriptive 
anatomy.  We  will  only  remark,  that,  they  are  united  by  their  roots 
With  a  determinate  point  of  the  mediastinal  face  of  their  cavities,  near 
which  the  pleura  is  reflected  upon  them. 

Development.  The  pulmonary  cavity  is  but  slightly  developed 
before  birth,  as  the  lung  within  it  is'  compressed  transversely,  and  is 
not  convex  posteriorly,  as  in  the  adult :  at  sixteen  years  of  age,  the 
posterior  processes  of  the  ribs  are  developed,  and  extend  the  pulmonary 
cavity  on  .this  side,  which  at  the  same  time  passes  beyond  the  plane 
of  the  spine. 


PULMONARY  CAVITIES.  177 

Varieties.  The  pulmonary  cavities  present  numerous  individual 
varieties  :  in  the  female  who  is  pregnant,  and  during  expiration,  they 
are  much  smaller  than  in  the  opposite  case,  where  their  costo-dia- 
phragmatic  sinus  is  vefy  much  enlarged. 

Pathological  and  operative  deductions.  In  acephalous  fetuses,  the 
two  pulmonary  cavities  are  deficient ;  the  lungs  are  not  formed,  most 
of  the  median  thoracic  organs  do  not  exist,  and  when  the  region  of  the 
ribs  is  seen,  we  find  below  it  only  cellular  tissue  infiltrated  with  serum. 
The  adhesion  which  always  supervenes  accidentally  between  two 
contiguous  layers  of  the  serous  membrane,  often  completely  or  partially 
closes  this  cavity.  If  we  do  not  describe  here  the  different  forms  of 
these  adhesions,  nor  their,  formation  nor  organization,  these  circum- 
stances should  be  carefully  noted,  because  they  modify  the  prognosis 
of  penetrating  wounds  of  this  region,  which  thus  become  nearly  as 
slight  as  those  which  are  not  penetrating :  in  fact,  when  the  adhesions 
have  closed  the  pulmonary  cavity,  neither  pleurisy,  nor  internal  effu- 
sion, nor  hernia  of  the  lung,  is  to  be  feared  ;  hemorrhage  can  be  easily 
stopped  by  compression,  and  if  emphysema  supervenes,  it  may  be 
removed  by  a  free  incision.  The  old  cartilaginous  or  osseous  adhe- 
sions, compensating  for  the  inconvenience  they  cause  by  their  firm  pro- 
tection, sometimes  form  a  kind  of  internal  shield,  capable  of  arresting 
wounding  instruments,  and  prevent  them  from  producing  wounds 
which  would  otherwise  be  fatal.  In  the  usual  state,  wounding  instru- 
ments, which  are  sometimes,  but  rarely,  arrested  in  their  course  by  the 
ribs,  open  the  pulmonary  cavity,  and  then  injure  the  lung.  This  organ 
extends  to  every  part  in  inspiration,  but  in  expiration  it  leaves  the 
costo-diaphragmatic  sinus,  and  consequently  it  cannot  then  be 
wounded  in  this  part. 

The  inevitable  result  of  the  simplest  penetrating  wound  of  the 
thorax,  is  the  immediate  entrance  of  air  into  the  cavity,  the  crowding 
back  of  the  lung,  which  is  then  separated  from  the  ribs  by  a  certain 
space,  and  more  or  less  hinders  respiration,  and  the  discharge  during 
expiration  of  a  portion  of  gas  introduced  in  inspiration.  If  the  wound 
be  narrow,  these  phenomena  are  very  much  marked,  and  the  alternate 
entrance  and  expulsion  of  the  air  from  the  wound,  are  attended  with  a 
loud  rustling,  resulting  from  the  vibration  of  its  lips  :  if  its  course  be  ob- 
lique, the  air  enters  the  adjacent  cellular  tissue,  and  produces  the  first 
kind  of  emphysema  :  the  second  exists  when  the  lung  itself  is  injured : 
the  air  which  emerges,  passes  from  this  organ  into  the  pleura,  then  into 
the  external  cellular  tissue  through  the  wound :  this  second  kind  of 
emphysema  supervenes,  also,  without  an  external  wound,  when  the 
fragments  of  a  fractured  rib  have  been  pushed  toward  the  lung. 
When  there  is  a  penetrating  wound  of  any  size,  but  little  or  no  em- 

23 


178  TOPOGRAPHICAL  ANATOMY. 

physema  exists;  hence, it  is  for  this  reason,  that  narrow  wounds,  with 
this  complication,  are  enlarged,  or  that  we  cut  upon  a  fracture  of  the 
ribs  attended  with  emphysema  :  when  the  ribs  are  broken,  this  opera- 
tion is  also  performed  for  the  double  purpose  of  removing  the  infiltra- 
tion of  air,  and  of  raising  the  fragments  which  irritate  the  lung1.  The 
effusions  which  occur  in  one  of  the  pulmonary  cavities,  press  the 
lung,  and  cause  it  to  collapse  against  the  mediastinum,  which  they 
also  depress  sometimes,  so  as  to  contract  the  opposite  cavity  very 
much,  and  to  remove  the  heart  from  its  normal  position  :  hence,  the 
respiration  is  still  more  obstructed  ;  hence,  also,  the  error  of  many, 
who  think  that  congenital  transpositions  of  the  heart,  or  dilatations,  of 
this  organ  exist,  which  are  riot  seen  in  post  mortem  examinations. 
When  pus  is  formed  in  the  chest,  the  wall  of  the  diaphragm  is  crowded 
towards  the  abdomen,  the  costo-diaphraginatic  sinus  is  very  much 
enlarged,  the  ribs  are  thrown  outward  and  are  immoveable :  the  lung 
often  forms  adhesions  in  its  forced  position,  and  then,  if  the  patient  is 
cured,  the  depression  of  the  costal  region,  already  mentioned,  super- 
venes. Valentine  asserts,  that  in  effusions  of  blood,  this  fluid,  after 
descending  to  the  lower  part  of  the  pulmonary  cavity,  passes  into  the 
cellular  tissue,  and  an  echymosis  appears  in  the  loins.  This  infiltra- 
tion, which  cannot  take  place  except  the  blood  has  transuded  through 
the  pleura,  is  not  constant.  This  is  not  the  place  for  mentioning  the 
different  modes  of  examining  the  chest,  but  we  must  remark  that  these 
results  vary  according  to  the  points  examined ;  this  should  be  remem- 
bered :  at  the  upper  part,  the  walls  of  the  chest,  as  we  have  stated, 
are  enlarged  by  the  thickness  of  the  shoulder,  and  auscultation  and 
percussion  are  there  difficult :  at  the  lower  part,  the  relations  between 
the  chest  and  the  abdomen  are  such,  that  in  employing  the  modes  of 
investigation,  it  must  be  made  on  both  sides:  thus,  for  instance,  the 
chest,  when  struck  at  the  lower  part  of  the  left  side,  resounds  mode- 
rately if  the  stomach  be  empty,  but  very  much,  on  the  contrary,  if  this 
viscus  be  distended  with  gas;  the  sound  is  very  dull  if  the  stomach 
be  filled  with  food :  thus,  although  percussion  may  be  used  here  for 
the  chest,  it  also  shows  the  state  of  the  abdominal  viscera ;  so,  likewise, 
on  the  right,  by  percussion  at  the  lower  part,  we  ascertain  the  state  of 
the  pulmonary  cavity  and  of  the  liver.  The  centre  of  the  sides  of  the 
chest  is  the  most  proper  point  for  using  the  method  of  exploration  ; 
because  they  are  thinner  than  above,  and  also  because  we  become 
acquainted  only  with  the  state  of  the  thorax.  Percussion,  also, 
when  applied  anteriorly  and  posteriorly,  makes  us  acquainted  with 
the  mediastinum  and  its  organs. 


ABDOMEN. 


CHAPTER        III. 


O  P       T  H  E       ABDOMEN. 

The  abdomen,  derived  from  the  Latin  word  abdere,  to  conceal,  the 
belly,  <fcc.  &c.,  comprises  all  that  part  of  the  trunk  which  contains,  in 
the  mammalia,*  most  of  the  alimentary  canal,  the  urinary  and  the  ge- 
nital organs,  and  which  supports  the  inferior  .or  posterior  limbs,  when 
they  exist.  The  abdomen  has  very  distinct  limits :  it  is  continuous  with 
the  chest  above,  and  is  distinguished  from  it  by  a  curved  line,  concave 
upward,  which  is  very  elevated  anteriorly,  but  less  so  posteriorly; 
this  is  the  prominence  of  the  cartilaginous  edge  of  the  last  ribs  •  these 
external  limits,  however,  are  not  those  of  the  abdominal  cavity.  The 
first  section  of  the  abdominal  limbs,  the  haunch,  belongs  in  the  inside 
to  this  important  part  of  the  trunk.  The  abdomen  is  situated  mostly 
above  the  centre  of  the  body.  Its  form  is  elongated:  it  is  slightly 
oval,  and  differs  in  the  sexes  :  its  direction  is  generally  that  of  a  curve, 
concave  posteriorly :  its  size  varies,  as  will  be  stated  below. 

If  we  consider  its  exterior  only,  the  abdomen  seems  separated,  very 
symmetrically,  into  two  parts,  by  the  median-  line  ;  but  this  is  not  the 
case  internally.  In  no  part  is  the  raphe  more  distinct  than  in  this. 

Structure.  The  skeleton  of  this  region  is  the  lumbar  portion  of  the 
spine  and  the  pelvis ;  these  parts,  with  the  base  of  the  chest,  form  a 
vast  fissure  open  anteriorly  ;  it  is  also  composed  of  muscles  of  different 
characters,  vessels,  and  nerves. 

Development.  The  abd  omen  is  the  first  part  of  the  body  formed  on  the 
umbilical  vesicle,  with  which  it  is  united :  they  are  soon  separated,  how- 
ever, by  a  short  pedicle,  the  rudiment  of  the  umbilical  cord.  This  cord 
then  extends  rapidly,  so  that  at  birth,  it  equals  the  length  of  the  child :  at 
first  it  proceeds  from  the  lower  part  of  the  body,  and  then  its  position, 
in  proportion  to  the  entire  body,  is  more  and  more  elevated.  During 
the  whole  of  fetal  existence,  and  even  after  birth,  the  abdomen  retains 
marks  of  its  premature  appearance  :  its  size,  considered  proportionally 
to  that  of  the  other  parts  of  the  body,  is  greater  than  in  the  adult.  In 

*  In  the  other  vertebral  animals,  the  diaphragm  is  deficient,  the  abdomen  and  chest  are 
united,  and  form  only  one  large  splanchnic  cavity.' . 


!8°  TOPOGRAPHICAL    ANATOMY. 

the  young  child,  the  abdominal  fat  is  all  external,  and  seems  to  retreat 
internally  as  age  advances  :  however,  at  forty-five  or  fifty  years  of  age, 
the  sub-cutaneous  fat  of  the  abdomen  often  reappears.  The  first  de- 
velopment in  respect  to  the  separate  pieces  which  primitively  form  the 
abdomen,  and  the  manner  in  which  its  pieces  are  approximated,  differs 
in  no  respect  from  that  of  the  trunk. 

Varieties.  In  the  female,  the  abdomen  is  larger  than  in  the  male  ; 
it  is  proportionally  higher  also  :  the  large  extremity  of  the  oval  which 
it  represents  looks  downward,  the  opposite  is  true  in  the  male.  The 
abdomen  presents  numerous  individual  varieties,  especially  in  respect 
to  size. 

Finally,  the  external  form  of  the  abdomen  constantly  changes :  it 
tumefies  after  eating,  during  inspiration,  and  collapses  under  opposite 
circumstances.  Its  direction  also  changes  in  different  attitudes.  Du- 
ring pregnancy,  it  is  distended  in  every  part,  especially  anteriorly. 

Uses'.  The  abdominal  part  contains  most  of  the  alimentary  canal, 
the  urinary  and  genital  organs  :  it  protects  them  all,  and  facilitates 
their  action  by  its  motions.  Its  muscles  frequently  contract  for  pur- 
poses disconnected  with  the  abdomen,  for  respiration  or  for  the  general 
motions  of  the  body ;  these  considerations  must  be  kept  in  view,  in 
order  to  form  our  opinions  of  the  numerous  diseases  of  the  abdomen, 
particularly  of  hernias,  The  early  development  of  the  abdomen,  and 
especially  its  primary  formation,  implies  that  it  cannot  be  entirely  ab- 
sent, even  in  the  greatest  monstrosities  ;  it  may  be  called  the  root  of  the 
individual,  and  when  this  root  is  deficient,  the  individual  cannot  form 
even  irregularly.  In  the  abdomen  we  must  examine  the  cavity  and 
its  parietes  ;  we  wilt  commence  with  the  latter. 


ARTICLE        I  . 


The  circumference  of  the  abdomen  is  generally  divided  into  ante- 
rior, posterior,  lateral,  superior,  and  inferior  parietes.  This  division, 
which  is  generally  good,  cannot  be  admitted  in  topographical  anatomy 
as  the  base  of  the  abdominal  regions,  because  it  is  not  always  founded 


ABDOMINAL  PAR1ETES.  181 

on  exact  limits,  or  differences  of  structure;  thus,  for  instance,  the 
anterior  and  lateral  walls  are  uniform  in  every  part,  they  have  the 
same  structure ;  it  would  therefore  be  inconvenient  to  separate  their 
description,  and  further  to  subdivide  them  artificially  into  secondary 
regions :  this  would  render  us  liable  to  repetitions,  and  would  obscure 
a  subject  which  is  naturally  clear. 

Although  the  abdominal  parietes  are  very  different  in  every  respect, 
they  have  also  some  analogies,  on  which  we  must  dwell  for  a  moment : 
all  have  two  faces ;  one  is  internal  and  serous  ;  the  other  is  external, 
and  is  generally  covered  with  skin  ;  the  upper  wall  is  the  only  excep- 
tion to  this.  They  are  provided  with  many  aponeuroses,  and  these 
form  openings  for  the  vessels.  These  openings  are  frequently  only 
the  commencement  of  the  canals  or  passages  which  pass  obliquely 
through  the  parietes  of  the  abdomen  :  they  contain  with  the  vessels  a 
very  loose  cellular  tissue,  with  some  pieces  of  fat,  and  are  closed  on  the 
inside  by  the  serous  membrane  of  the  abdomen. 

Uses.  The  parietes  of  the  abdomen  are  contractile,  and  often  act 
in  this  manner :  they  resist,  on  account  of  their  compact  structure. 
Here  we  remark,  that  nature  has  formed  the  aponeurosis  distinct  from 
the  muscles,  in  those  parts  against  which  the  viscera  press  most  fre- 
quently, and  there  also  they  are  more  resisting :  they  are  very  strong 
and  numerous  at  the  base  of  the  anterior  wall,  and  particularly  in  the 
inferior  j  this  latter  arrangement  is  very  remarkable  in  the  human 
species  ;  the  first,  on  the  contrary,  in  the  great  quadrupeds  :  these  facts 
from  human  and  comparative  anatomy  would  establish,  if  necessary, 
that  man  was  formed  for  the  erect  and  other  animals  for  the  horizontal 
posture. 

Pathological  and  operative  deductions.  The  openings  or  the  vas- 
cular canals  of  the  abdominal  parietes,  are  the  parts  through  which 
the  viscera  in  most  cases  pass  and  form  hernias  :  the  looseness  of  the 
cellular  tissue  which  closes  these  passages  predisposes  to  these  affec- 
tions :  but  in  return,  their  oblique  direction,  which  is  similar  to  that  of 
the  ureters  through  the  walls  of  the  bladder,  is  a  precaution  taken  by 
nature  to  prevent  them.  The  adipose  substance  which  they  contain 
when  the  person  becomes  very  fat,  at  first  dilates  the  opening,  and 
then  destroys  its  elasticity  ;  and  if  in  these  cases,  the  person  loses  his 
flesh,  these  elastic  portions  rapidly  disappear,  and  hernias  are  easily 
produced.  Finally,  the  fat  of  the  abdominal  openings,  when  very 
abundant,  may  be  developed  on  the  outside,  and  by  its  weight  may 
draw  downward  the  part  of  the  peritoneum  which  covers  the  opening 
on  the  inside,  and  thus  cause  the  formation  of  a  true  sac,  which  re- 
quires only  a  few  folds  of  intestine,  to  constitute  a  complete  hernia, 
called  a  fatty  hernia. 


1S2  TOPOGRAPHICAL    ANATOMY. 


.    PARAGRAPH        FIRST. 

ANTERIOR   AND    LATERAL   ABDOMINAL    PAR1ETES. 

These  portions  of  the  circumference .  of  the  abdominal  cavity  are 
continuous :  they  are  similar  in  respect  to  the  absence,  of  an  osseous  por- 
tion which  serves  as  a  point  of  support :  they  are  formed  in  almost 
every  part  by  the  same  layers.  From  these  considerations  they  should 
be  blended  in  one  region,  which  Beclard  proposed  to  call  the  costo-iliac 
region,  from  the  name  of  the  two  parts  of  the  skeleton  between  which 
it  is  included. 


ANTERIOR   AND.  LATERAL   ABDOMINAL 
(COSTO-ILIAC)  REGION. 

The  form  of  this  region,  when  detached  and  extended  upon  a  plane, 
is  that  of  the  Maltese  cross  ;  it  presents  two  lateral  prolongations,  which 
enter  between  the  iliac  crest  and  the  false  ribs ;  and  two  others,  one 
superior,  extending  into  the  substernal  fissure  of  the  base  of  the  thorax; 
the  other  into  that  of  the  superior  edge  of  the  pelvis  anteriorly.  Its 
limits  are  well  denned :  above,  the  thorax,  the  base  of  which  projects 
externally ;  below,  the  pelvis  ;  on  the  outside,  the  prominence  of  the 
external  edge  of  the  sacro-spinalis  muscle.  Its  thickness  varies ;  upon 
the  median  line,  it  is  four  lines ;  at  the  rectus  muscle,  it  is  ten  lines  ; 
on  the  outside  of  this  muscle,  from  six  to  eight  lines.  Generally,  this 
region  is  thicker  below  than  above. 

It  presents  two  faces ;  one  .cutaneous,  the  other  peritoneal.  The 
first  presents  on  the  median  line  a  raphe,  which  is  very  distinct  and 
situated  at  the  base  of  a  variable  depression ;  in  the  centre,  the  umbilical 
cicatrix;  above,  a  triangular  cavity,  the  .substernal  fossa,  the  pit  of 
the  stomach  ;  below,  some  hairs  continuous  with  those  of  the  pubis  ; 
upon  the  sides  of  the  median  raphe,  a  prominence  which  is  .broader 
and  as  it  were  expanded  above,  belonging  to  the  rectus  muscle ;  en- 
tirely on  the  outside,  a  surface  concave  from  above  downward,  convex 
transversely.  Finally,  in  fat  individuals,  this  face  slightly  projects 
above  the  level  of  the  haunch  and  the  groin.  The  second  is  smooth, 
and . generally  concave,  except  when  contracted;  we  find  there,  the 
posterior  face  of  the  umbilicus,  whence  proceed,  superiorly  on  the 
right,  the  cord  formed  by  the  obliteration  of  the  umbilical  vein,  and  its 
falciform  peritoneal  fold,  while  downward,  descend  the  two  umbilical 
arteries  arid  the  obliterated  urachus,  then  their  peritoneal  folds,  which 
diverge  and  form  a  triangle,  the  base  of  which  is  inferior.  The  um- 


COSTO-ILIAC  REGION.  183 

bilical  arteries  cause  two  peritoneal  fossae,  which  vary  in  their  position ; 
they  are  of  little  importance,  and  are  termed  the  inguinal  fossae. 

Structure.  —  1.  Elements.  Properly  speaking,  the  costo-iliac  region 
has  no  skeleton,  although  Meckel  considers  the  lineaalba  and  the  ten- 
dinous intersections  of  the  rectus  muscle,  as  representing  the  .sternum 
and  the  ribs.  Several  muscles  belong  to  it ;  the  recti  and  pyramidales 
muscles  on  the.  median  line,  the  latissimus  dorsi  posteriorly,  the  two 
obliqui  and  the  transversalis  on  the  sides ;  their  description  does  not 
belong  to  topographical  anatomy ;  we  will  only  mention  that  the  infe- 
rior edge  of  the  obliquus  externus  muscle,  by  folding  from  below  up- 
ward and  from  before  backward,  forms  Gimbernat's  ligament,*  and  is 
continuous  with  the  fascia  transversalis  and  the  fascia  iliaca,  as 
we  shall  mention  when  describing  the  groin;  this  fold  forms  the 
crural  arch,  the  Fallopian  or  Poupart's  ligament,  an  arch,  the  direc- 
tion of  which  is  oblique  downward  and  inward;  and  this  is 
attached  to  the  superior  and  anterior  spine  of  the  ilium,  on  the  pubis, 
and  measures  by  its  length  the  space  between  these  two  points.  The 
crural  arch  adheres  to  the  ilium  in  only  one  place  ;  it  separates,  on  the 
contrary,  on  the  pubis,  into  two  fasciculi ;  one,  the  external  pillar  of  the 
ring,  is  inferior,  and  is  attached  to  the  spine  of  the  pubis  ;  the  internal 
pillar  of  the  ring  is  superior,  and  terminates  before  the  symphysis, 
crossing  with  that  of  the  opposite  side.  Between  these  pillars  is  an 
oblique  opening,  the  inguinal  ring,  the  base  of  which  rests  on  the  pubis, 
while  its  upper  side  corresponds  to  the  point  of  separation  of  the  two  pil- 
lars, and  is  formed  by  some  fibres  which  interlace  perpendicularly  to 
the  direction  of  the  pillars.  The  aponeurosis  of  the  obliquus  externus 
muscle,  by  reflecting  in  this  .  manner,  forms  a  groove  or  channel  open 
above,  on  the  external  third  of  which  the  obliquus  internus  and  trans- 
versalis muscles  are  attached  together,  while  their  lower  edge  is  fleshy, 
and  has  a  horizontal  direction,  differing  in  this  respect  from  that  of  the 
obliquus  externus  muscle ;  from  this  opposite  arrangement  it  follows 
that  the  obliquus  internus  and  the  transversalis  muscles  on  the  inside,  are 
not  contiguous  to  the  aponeurosis  of  the  obliquus  externus,  in  a  trian- 
gular space  which  corresponds,  as  we  shall  see,  to  the  posterior  wall  of 
the  inguinal  canal ;  the  three  muscles  of  the  abdominal  wall  of  which 
we  are  speaking  are  aponeurotic  internally  and  anteriorly,  and  form  a 
sheath  for  the  recti  and  pyramidales  muscles,  which  is  perfect  anteriorly, 
imperfect  posteriorly ;  on  the  median  line,  they  unite  with  each  other, 
and  with  those  of  the  opposite  sides,  in  a  tendinous  raphe,  which  con- 
stitutes the  linea  albaj  Considered  as  a  special  part,  this  line  is  attached 


*  We  shall  treat  more  fully  of  this  ligament  hereafter. 

t  Some  include  under  this  term,  all  the  space  comprehended  between  the  two  recti  muscles. 


184  TOPOGRAPHICAL  ANATOMY. 

above  to  the  xyphoid  appendix,  below  to  the  pubis.  Its  anterior  and 
posterior  faces  are  intimately  united  to  the  skin  and  peritoneum ;  we 
find  there  many  openings,  besides  the  umbilical  ring.  They  give  pas- 
sage to  vessels  which  proceed  from  the  deep  face  of  the  abdominal  wall, 
and  go  outward  or  vice  versa ;  we  sometimes  find  large  masses  of  fat 
in  the  course  of  these  vessels ;  the  vascular  openings  of  the  linea  alba 
are  more  numerous  at  the  umbilicus  and  above  it,  than  at  any  other 
part.  The  linea  alba  is  more  developed  in  the  large  animals,  and  is 
very  elastic  ;  it  forms  in  them  a  large  spring,  which  supports  the  ab- 
dominal viscera,  and  assists  the  action  of  the  muscles.  Two  ap'o- 
neuroses  appear  also  in  this  region,  and  must  be  described  minutely : 
they  are  stronger  below  and  on  the  outside  of  the  rectus  muscler  than 
in  any  other  part :  there  also,  as  we  have  already  said,  the  obliquus 
internUs  and  the  transversalis  muscles  do  not  descend,  and  there  the 
wall  of  the  abdomen  is  strengthened  in  another  manner.  These 
aponeuroses  are  termed  the  superficial  and  the  transverse  fascia. 

The  superficial  fascia  of  Camper  is,  in  the  male,  a  fibro-cellular 
layer,  continuous  above  with  the  sub-cutaneous  cellular  tissue  of  the 
thorax,  descending  below  into  the  testicular  region,  where  it  forms  the 
dartos,  and  to  the  anterior  part  of  the  thigh,  where  it  soon  terminates 
in  the  sub-cutaneous  tissue,  and  is  also  attached  by  one  of  its  folds  on 
the  fascia  lata,  below  the  crural  arch  ;  it  is  attached  on  the  outside  to 
the  iliac  crest,  and  descending  a  little  on  the  haunch,  it  is  formed  of 
several  layers,  between  which  the  superficial  vessels  and  the  fat  of  the 
abdomen  are  situated.  One  of  its  faces  rests  on  the  obliquus  externus 
muscle,  on  the  haunch,  the  testicular  region^  and  the  thigh ;  the  other 
is  united  to  the  skin.  In  the  large  animals,  the  superficial  fascia,  like 
the  linea  alba,  is  very  much  developed,  and  is  extremely  elastic. 

The  transverse  fascia'  of  Cooper,  a  reflected  fold  of  the  aponeurosis  of 
the  obliquus  externus  muscle,  does  not  really  exist,'  except  in  a  triangular 
space,  circumscribed  by  the  external  edge  of  the  rectus  muscle,  the 
crural  arch,  and  an  imaginary  line  drawn  horizontally  from  the  anterior 
and  superior  spine  of  the  ossa  ilia,  toward  the  rectus  muscle ;  there 
only  is  it  necessary  to  strengthen  the  abdominal  wall,  as  we  have  seen. 
This  aponeurosis  is  continuous1  on  the  inside  with  the  external  edge  of 
the  tendon  of  the  rectus  muscle,  below,  in  all  its  extent,  with  the  crural 
arch,  and  on  the  outside  only,  with  the  iliac  fascia.  By  its  anterior 
face  it  is  separated  below  from  the  aponeurosis  of  the  obliquus  externus 
muscle  by  the'  inguinal  canal;  above^  it  rests  on  the  transversalis 
muscle ;  posteriorly,  it  bounds  the  peritoneum  and  the  epigastric  artery. 
Two  fingers'  breadth  on  the  inside  of  the  iliac  spine,  or  just  above  the  cru- 
ral arch,  the  transversalis  fascia  presents  an  elongated  opening,  the  inside 
of  which  is  falciform  and  very  resisting,  and  the  outer  side  of  which  is. 


COSTO-ILIAC  REGION.  185 

very  weak :  this  is  the  upper  orifice  of  the  inguinal  canal.  In  this 
place,  the  aponeurosis  is  only  apparently  interrupted,  it  is  depressed 
in  the  form  of  a  funnel,  and  forms  the  common  sheath  of  the  testis 
and  of  its  cord. 

The  skin  of  this  part  of  the. abdomen  is  very  strong,  and  its  areolae 
are  very  distinct :  it  is  very  hairy  near  the  pubis.  .The  peritoneum 
presents  nothing  peculiar,  except  its  folds,  which  we  have  already 
mentioned  ;  its  adhesion  is  more  or  less  intimate,  and  is  ve.ry  firm  on 
the  median  line. 

The  arteries  arise  in  the  centre  from  the.  substernal,  the  epigastric, 
and  the  sub-cutaneous  abdominal  arteries,  on  the  outside  from  the  last 
intercostal  arteries,  from  the  lumbar  arteries  which  terminate  there, 
and  from  the  circumflex  iliac,  which' is  situated  on  the  iliac  boundary 
of  the  region.  As  a  general  rule,  these  external  arteries  become  less 
(Jeep  as  they  approach  the  median  line,  and  particularly  the  umbilicus. 
The  veins  follow  the  cpurse  of  the  arteries  ;  the  superficial  are  broad 
and  numerous.  The  lymphatic  vessels  are  deep  or  superficial :  the 
first,  are  few  in  number,  follow  the  arteries,  and  go  to  the  iliac, 
lumbar,  and  substernal  ganglions;  among  the  second,  those  of  the 
sub-umbilical  portion  converge  toward  the  inguinal  ganglions ;  those  of 
the  supra-umbilical  portion  terminate  in  the  axillary  ganglions.  The 
nerves  come  from  the  last  intercostal  and  lumbar  pairs.  The  superficial 
cellular  tissue  is  loose  ;  'the  sub-peritoneal  is  more  dense  ;  on  the  me- 
dian line  it  is  very  dense,  superficially  and  deeply  ;  the  fat.  particularly 
is  situated  superficially.  The  spermatic  cord,  or  the  round  ligament, 
pass  outward,  through  the  abdominal  wall ;  but  in  the  fetus,  only  the 
umbilical  cord  passes  through  it. 

2.  Relations.  The  relations  of  the  costo-iliac  region  vary,  according 
as  they  are  considered  on  the  median  line,  at  the  rectus  muscle,  and 
on  the  outside  of  it ;  we  will  examine  them  there  in  these  different 
points.  On  the  median  line,  we  find  successively,  the  skin,-  which  is 
very  adherent,  depressed  and  hairy  at  the  lower  part,  a  thick  layer  of 
cellular  tissue,  the  linea  alba  and  its  vascular  openings,  which  are 
numerous  around  the  umbilicus  ;  this  latter  is  corrugated,  and  very 
resisting ;  these  openings  are  more  or  less  dilated  by  particles  of  fat ;  a 
cellular  layer,  which  is  very  dense,  also  exists  there,  especially  around 
the  umbilicus  ;  finally,  in  this  point  only,  are  situated  the  umbilical 
cord  and  the  urachus ;  then  the  whole  of  the  peritoneum  adheres 
firmly  to  the  preceding  layers  the  entire  length  of  the  region. 

2.  At  the  rectus  muscle,  which  is  visible  when  the  trunk  is  flexed, 
we  find  successively  ;  the  skin,  which  adheres  slightly,  the  superficial 
fascia,  the  anterior  wall  of  the  sheath  of  the  rectus  muscle,  which  is 
doubly  formed  by  the  two  oblique  muscles  above,  and  is  triple  below, 

24 


186  TOPOGRAPHICAL   ANATOMY. 

by  the  addition  of  the  transversalis ;  sometimes  this  contains,  in  the 
doubling  of  its  layers,  the  pyramidalis  muscle,  and  this  is  sometimes 
situated  on  the  rectus  muscle.  Next  comes  the  rectus  muscle,  then  in 
its  thickness  and  behind  it,  the  epigastric  artery  below,  and  above,  the 
internal  mammary  artery,  which  proceeds,  toward  the  umbilicus  ;  be- 
hind this  muscle  superiorly,  the  posterior  wall  of  the  sheath  of  the  rectus 
muscle,  which  wall  is  doubled  from  the  obliquus  internus  and  the 
transversalis  below,  the  sub-peritoneal  cellular  tissue  and  the  perito- 
neum, which  we  find  above  only  under  the  preceding  aponeurosis,  to 
which  it  adheres  firmly. 

3.  On  the  sides  of  the  rectus  muscle,  we  find  successively  ;  the  skin, 
which  adheres  slightly ;  the  superficial  fascia.,  which  frequently  con- 
tains between  its  layers  much  fat ;  the  sub-cutaneous  artery,  which  is 
directed  obliquely  from  the  centre  of  the  crural  arch  toward  the  um- 
bilicus ;  the  veins  and  superficial  lymphatic  vessels ;  the  obliquus 
externus  muscle,  with  its  aponeurosis,  and  posteriorly  only  on  the 
•same  plane,  the  latissimus  dorsi  muscle  ;  then  between  the  two,  a  tri- 
angular space,  where  the  obliquus  internus  muscle  is  situated,  in 
which  space  the  abdominal  wall  is  weaker  than  in  the  adjacent  parts. 
Next,  the  obliquus  internus  muscle  is  seen  in  every  part,  excepting 
below  and  on  the  outside  of  the  rectus  muscle,  in  a  triangular  space 
already  mentioned,  where  the  aponeurosis  of  the  obliquus  externus 
corresponds  to  the  inguinal  canal :  the  transversalis  muscle  lies  under 
the  obliquus  internus  muscle,  which  covers  the  transverse  fascia  only 
below,  while  we  find  more  deeply  a  loose  cellular  tissue,  containing 
the  epigastric  arteries,  which  are  directed  obliquely  from  the  centre  of 
the  crural  arch  toward  the  umbilicus,  and  finally  the  peritoneum, 
which  adheres  but  slightly.  The  lumbar  vessels  and  nerves,  which 
go  obliquely  downward  and  forward,  are  situated  at  the  flank,  between 
the  transversalis  and  the  obliquus  internus  muscles  ;  anteriorly,  on  the 
contrary,  between  this  and  the  obliquus  externus,  they  are  extremely 
small.  It  follows  from  these  remarks,  that  the  abdominal  wall  has  no 
large  vessels  on  the  outside  of  the  umbilicus  and  rectus  muscle,  the 
epigastric  and  mammary  arteries  being  turned  inward  ;  and  that  the 
lumbar  vessels  of  this  part  are  only  capillary  twigs. 

Such  are  the  relations  of  nearly  all  the  ilio-costal  region  ;  but  there 
is  one  point  where  these  relations  are  so  important  that  they  demand 
a  more  minute  examination ;  it  is  that  of  the  inguinal  canal,  which 
serves  for  the  transmission  of  the  spermatic  cord  in  the  male,  the  round 
ligament  of  the  uterus  in  the  female. 

Inguinal  canal.  The  inguinal  canal  is  flattened  from  before  back- 
ward :  it  is  an  inch  and  a  half  long,  and  its  direction  is  oblique 
forward  and  downward :  it  occupies  the  abdominal  wall  in  a  space 


COSTO-ILIAC  REGION.  187 

already  mentioned,  a  space  which  is  bounded  on  the  inside  by  the 
rectus  muscle,  below  by  the  crural  arch,  above  by  the  lower  edge  of 
the  obliquus  interims  and  transversalis  muscles  united :  this  part  of 
the  abdominal  wall  would  be  very  feeble,  unless  a  special  aponeurosis, 
the  transversalis,  was  added. 

The  inguinal  canal  presents  a  central  part  and  two  openings  ;  the 
central  part  presents  four  parietes  ;  one  of  the  two  openings  is  superior, 
the  other  inferior. 

1.  The  anterior  wall  of  this  passage  is  formed  by  the  aponeurosis 
of  the  obliquus  externus  muscle,  covered  by  the  superficial  fascia,  the 
tegumentary  vessels,  and  the  skin.  2.  The  posterior  wall  is  formed 
by  the  transversalis  fascia,  covered  posteriorly  by  the  epigastric  artery 
and  the  peritoneum.  3.  The  lower  wall  is  formed  by  the  reflected 
groove  of  the  crural  arch.  4.  The  upper  wall  is  bounded  less  dis- 
tinctly, by  the  lower  edge  of  the  obliquus  internns  and  transversalis 
muscles. 

The  interior  of  the  canal  is  also  lined  by  the  canalicular  prolonga- 
tion of  the  transversalis  fascia.  The  upper  or  peritoneal  orifice  looks 
backward,  and  has  the  form  of  a  fissure  ;  its  inside  is  falciform  and 
very  strong,  and  the  epigastric  vessels  are  situated  against  it ;  the  ex- 
ternal presents  nothing  remarkable  ;  this  orifice  belongs  entirely  to  the 
transversalis  fascia ;  it  is  closed  by  the  peritoneum,  which  presents  there 
a  slight  depression,  and  is  extended  there  by  a  cellular  filament. 

The  lower  orifice  is  oblique,  and  has  already  been  described  ;  it  is 
the  inguinal  ring.  Its  circumference  gives  rise  to  a  thin  fibrous  expan- 
sion, which  descends  on  the  cord,  and  is  covered  by  the  superficial  fascia 
and  the  skin.  Farther,  when  cut  obliquely  outwards,  the  abdominal 
wall  is  very  much  weakened  in  this  point,  which  is  here  formed  only 
by  the  skin,  the  superficial  fascia,  the  very  thin  expansion  detached  from 
the  circumference  of  the  ring,  the  transversalis  fascia,  and  the  perito- 
neum. The  inguinal  canal  is  larger  in  the  male  than  in  the  female, 
and  contains  in  the  former  the  spermatic  cord,  and  in  the  female  the 
round  ligament  of  the  uterus,  a  cellular  prolongation  of  the  peritoneum, 
a  remnant  of  the  tunica  vaginalis,  or  of  the  canal  of  Nuck,  a  canal  of 
the  transverse  fascia,  the  cremaster  muscle,  and  some  adipose  tissue. 

The  inguinal  canal  is  at  first  very  narrow ;  it  enlarges  in  the  male 
after  the  descent  of  the  testicles  ;  in  the  first  periods  it  contains  the 
prolongation  of  the  peritoneum,  which  is  soon  obliterated ;  this  is  the 
neck  of  the  tunica  vaginalis  in  the  male,  and  the  canal  of  Nuck  in  the 
female. 

Development.  The  costo-iliac  region  is  formed  of  two  pieces,  which 
unite  on  the  raphe.  This  union  occurs  late  in  one  point,  and  there 
remains  during  the  whole  of  fetal  life  an  opening,  which  is  afterwards 


1-38  TOPOGRAPHICAL  ANATOMY. 

obliterated  ;  this  is  the  umbilical  ring,  through  which  the  umbilical 
cord  passes. 

Umbilical  ring.  This  opening  is  situated  at  first  far  below  the 
centre  of  the  body  ;'  it  arrives  at  this  point  the  sixth  month  of  preg- 
nancy ;  the  cicatrix,  which  replaces  it  in  the  adult,  occupies  a  higher 
region.  Its  circumference  is  entirely  fibrous,  and  adheres  loosely 
above  on  the  right  to  the  umbilical  vein;  it  is  formed  below  by  a 
straight  edge,  by  which  it  is  intimately  united  to  the  urachus  and  to 
the  umbilical  arteries.  The  peritoneum,  and  even  the  intestine,  pass 
through  the  umbilicus  in  early  life,  and  go  into  the  cord  ;  after  birth, 
and  even  from  the  tenth,  week  of  fetal  existence,  this  is  not  seen  in  the 
normal  state  ;  its  size  is  inversely  as  the  age ;  in  the  adult,  its  parietes 
are  so  corrugated  and  so  near,  that  its  opening  is  seldom  permeable ; 
anteriorly,  it  is  covered  by  the  skin,  and  a  compact  cellular  tissue, 
posteriorly  by  the  peritoneum,  which. adheres  very  firmly. 

Varieties.  The  whole  ilio-costal  region  is  very  much  developed  in 
proportion  to  the  others  in  the  fetus.  In  old  men,  it  often  increases 
by  the  accumulation  of  fat  under-  the  skin.  In  the  female,  it  is  broader 
below  than  in  the  male  ;  it  is  thicker,  on  account  of  the  fat,  except  in 
those  who  have  borne  many  children  ;  in  the  female,  also,  the  inguinal 
canal  is  narrower ;  it  presents  many  other  individual  varieties,  in 
respect  to  resistance.  In  females  who  have  borne  many  children,  this 
region  is  flabby :  the  skin  which  covers  it  presents  at  the  lower  part 
numerous  cicatrices,  marks  of  its  distention. 

Uses.  This  region  possesses  a  very  great  resistance,  on  account  of 
the  muscles  and  their  aponeuroses,  which  form  the  layers,  the  fibres 
of  which  have  different  directions  in  each,  and  cross  obliquely :  the 
parts  where  it  is  feeble,  are  its  inguinal  part,  the.linea  alba  at  the  um- 
bilicus and  at  its  vascular  openings,  behind  the  space  included  between 
the  obliquus  externus  and  the  latissimus  dorsi.  This  wall  is  susceptible 
of  motions,  in  consequence  of  which  it  is  sometimes  convex,  and 
sometimes  concave  anteriorly.  ' 

Pathological  and  operative  deductions.  This  region  may  be  par- 
tially or  entirely  deficient  from  a  primitive,  arrest  of  development ;  the 
umbilicus  may  remain  open  after  birth,  and  allow  the  peritoneum  and 
intestine  to  pass  out.  Wounds  of  this  part  are  always  serious,  because 
the  cicatrix  which  follows  is  weaker  than  the  uninjured  wall,  and  be- 
cause they  thus  dispose  to  hernias ;  we  do  not  here  allude  to  the 
severity  of  penetrating  wounds;  they  give  rise  to  hernias  much 
more  quickly  the  lower  their  situation,  as  the  viscera  tend  to  this 
part  by  their  specific  gravity ;  hence  the  precept  to  divide  these 
wounds  upward.  This  wall  being  weakened'very  much  during  preg- 
nancy, is  sometimes  depressed  by  the  weight  of  the  intestines,  and  tu- 


COSTO-ILIAC  REGION.  189 

mors  form  which  are  termed  eventrations.  This  wall  is  punctured  in 
ascites :  the  slightly  vascular  state  of  the  part  which  corresponds  to 
the  outside  of  the  rectus  muscle  at  the  level  of  the  umbilicus,  explains 
why  this  point  is  so  frequently  selected  for  this  operation  ;  it  may  also 
be  performed. on  the  median  line,  excepting  at  the  lower  part,  where 
the  bladder  may  be  endangered,  as  we  shall  see  hereafter.  In  opera- 
tions oh  the  abdomen,  the  incisions  must  generally  be  made  horizon- 
tally, to  avoid  the  external  vessels- which  have  a  transverse  direction  : 
hence  in  hysterotomy'  performed  on  the  outside  of  the  rectus  muscle, 
the  method  of  Lauverjat  should  be  preferred  to  that  of  the  ancients, 
where  the  first  incision  is  made  parallel  to  the  median  line.  When 
performed  on  the  raphe,  this  operation  endangers  no  important  artery 
of  the  abdominal  parietes ;  this,  however,  may  not  be  the  case  with 
the  uterus.  The  size-of  the  afeolae  of  the  skin  and  of  the  portions  of 
cellular  tissue  in  this  part,  accounts  for  the  frequency  of  biles  and  of 
anthrax  in  this  region.  The  diseases  of  the  subumbilical  port-ion  of 
this  region  are  attended  with  the  engorgement  of  the  inguinal  lym- 
phatic glands,  those  of  the  part  above  the  umbilicus  cause  the  tume- 
faction of  the  axillary  ganglions,  as  may  be  imagined  from  the 
arrangement  of  the  lymphatic,  vessels.  This  region  is  necessarily  divi- 
ded, in  order  to  tie  the  aorta  and  the  external  and  internal  iliac 
arteries,  and  in  operating  for  artificial  anus,  when  the  rectum  is  de- 
ficient :  we  shall  mention  these  operations,  when  speaking  of  the 
posterior  wall  of  the  abdomen.  The  inguinal  qanal  is  larger  in  the 
male,  and  hence  inguinal  hernias  are  more  frequent ;  in  these-hernias, 
sometimes  the  viscera  pass  through  the  whole  canal,  proceeding 
through  its  upper  opening,  and  gliding  before  the  parts  which  it  con- 
tains :  these  are  the  external  inguinal  -hernias,  which  have  the  epigas- 
tric artery  on  the  inside  of  the  neck  of  their  sac  :  at  first,  these  hernias 
are  oblique  like  the  passage  through  which  they  pass,  but  at  a  later 
period,  they  gradually  crowd  back  the  inside  of  the  upper  opening,  en- 
large this,  and  bring  it  to  the  lower  orifice ;  they  are  then  direct : 
sometimes  the  viscera  depress  the  posterior  wall' of  the  inguinal  canal 
on  the  outside  of  the  rectus  muscle  :  in  fact,  in  this  place,  this  wall, 
formed  only  by  the  trans versalis  fascia,  is  much  more  feeble,  as  it  corre- 
sponds to  the  inguinal  ring,  and  wants  support  on  the  outside  :  in  this 
hernia,  termed  the  internal  inguinal  hernia,  and  which  has  the  epigas- 
tric artery  on  the  outside  of  its  neck,  the  viscera  are  situated  on  the 
inside  of  the  spermatic  cord  or  of  the  round  ligament,  and  are  enve- 
loped by  the  skin,  the.  superficial  fascia,  the  fibrous  expansion  of  the 
inguinal  ring  and  the  peritoneum,  the  tunriel-shaped  prolongation  of 
the  transverse  fascia  and  the  cremaster.  The  internal  hernias,  on 
account  of  the  manner  in  which  they  pass  through  the  canal,  are  al- 


190  TOPOGRAPHICAL  ANATOMY. 

ways  originally  directed  from  behind  forward.     The  tumor  which 
constitutes  inguinal  hernia  often  stops  in  the  canal,  and  it  is  then  bubo- 
nocele :  sometimes  the  adipose  bodies  of  the  inguinal  canal  enlarge 
and  form  lipomata,  which  resemble  epiploic   hernia :    these  adipose 
buttons  sometimes  draw  down  the  peritoneum  or  the  posterior  wall  of 
the  passage  to  which  they  adhere,  depress  them,  and  cause  the  forma- 
tion of  peritoneal  sacs,  into  which  the  intestines  soon  descend  ;  they 
there  form  fatty  inguinal  hernias,  which  may  be  external  or  internal. 
Sometimes  the  testicle  on  descending  into  the  scrotum  is  followed  by. 
a  fold  of  intestine,  then  the  neck  of  the  vaginal  tunic  cannot  be  oblite- 
rated, and  a  congenital  hernia  is  formed,  which  is  from  its  nature 
external :  sometimes,  if  this  cause  does  not  exist,  the  neck  of  this  tunic 
is  permeable,  and  then  if  it  becomes  the  seat  of  an  accumulation  of 
serum,  congenital  hydrocele  exists :  diseases  of  the  testicle  or  of  its 
cord,  by  drawing  this,  sometimes  bring  also  the  peritoneum  in  the  form 
of  a  sac  into  the  inguinal  canal.     The  lipomatpus  swelling  of  the  adi- 
pose masses  of  the  inguinal  canal  dilate  and  weaken  it :  if  then  the 
patient  suddenly  loses  flesh,  hernias  occur  easily ;  when  a  hernia  con- 
tinues a  long  time,  if  it  exactly  fills  the  canal,  its  neck  is  soon  oblite- 
rated; but  a  cellular  or  fibrous  filament  continues  in  the  inguinal 
canal,  which  resembles  that  of  the  neck  of  the  obliterated  sac  of  the  va- 
ginal tunic.     Sometimes  the  testicle  stops  in  the  inguinal  canal,  dilates  it 
and  weakens  it  much,  which  also  disposes  to  hernias  when  it  descends 
lower.     In  the  adult,  hernias  seldom  occur  through  the  umbilical  rin'g, 
but  through  the  openings  of  the  linea  alba,  which  are  very  numerous, 
and  are  very  near  each  other  ;  in  the  child,  however,  this  is  not  the 
case.     Umbilical  hernias  also  may  be  congenital.     We   have  men- 
tioned a  normal  hernia  of  the  small  intestine  through  the  umbilicus,  in 
the  early  months  of  fetal  existence,  which  continues  abnormally  in 
congenital  hernia.     Hernias  in  the  linea  alba  are  more  frequent  around 
and  above  the  umbilicus,  for  the  anatomical  reason,  that  the  number 
of  vascular  openings  is  greater  in  these  parts.     Vesicles  of  fat,  engaged 
in  the  openings  of  the  linea  alba,  their  frequent  enlargement,  the  traction 
they  exercise  on  the  peritoneum  to  which  they  adhere,  explain  the  forma- 
tion of  hernias  of  the  linea  alba,  a  formation  analogous  to  that  of  the 
fatty  inguinal  hernias  :  all  the  hernias  of  the  linea  alba,  including  those 
of  the  umbilicus,  are  remarkable  for  their  superficial  position ;  they 
are  enveloped  only  with  skin,  a  thin  layer  of  cellular  tissue,  and  the 
peritoneum.     Even  this  last  envelope  in  old  and  large  hernias  becomes 
so  thin,  that  it  is  hardly  visible,  and  seems  not  to  exist,  whence  some 
surgeons  have  asserted  that  it  is  never  present.     The  peritoneal  enve- 
lope, however,  always  exists  at  the  commencement,  but  the  hernia  soon 
increases,  and  the  peritoneum  adhering  on  the  median  line,  as  has 


LUMBAR  REGION.  191 

been  stated,  and  unable  to  yield,  is  corroded,  or  rather  is  enormously 
distended  and  is  absorbed,  and  we  find  no  traces  of  it.  The  absence 
of  the  obliquus  externus  muscle  posteriorly  in  the  posterior  abdominal 
wall,  and  the  feebleness  caused  by  this,  explains  the  formation  of 
hernias  in  this  point,  as  we  shall  mention  hereafter.  In  females  who 
have  borne  many  children,  the  recti  muscles  are  very,  much  separated, 
the  openings  in  the  linea  alba  are  dilated ;  hence  the  frequency  of 
hernias  in  this  point. 


PARAGRAPH       SECOND. 
OF    THE     POSTERIOR.    ABDOMINAL     WALL. 

The  posterior  wall  does  not  present  externally  very  prominent  limits 
below ;  above,  the  prominence  of  the  lower  edge  of  the  twelfth'rib,  and 
on  the  outside,  the  projection  of  the  sacro-spinal  muscles,  mark  its 
boundaries  a  little  better.  This*  wall,  however,  like  the  preceding, 
above  the  first  rib,  belongs  also  to  the  thorax  and  the  abdomen  ;  it  is 
constituted  by  the  lumbar  and  iliac  regions,  and  forms  by  uniting  to  the 
anterior  wall,  the  groin. 

» 

1  .      L  t»M  BAR      REGION* 

P 

* 

This  region  is  unmated,  symmetrical,  and  is  situated  in  an  antero- 
posterior  median  plane  ;••  its  limits  are  very  exact  above,  the  oblique 
line  represented  by  the  twelfth  rib ;  below,  the  iliac  crest,  laterally, 
the  outer  edge  of  the  sacro-spinalis  muscle,  which  is  prominent  in  very 
powerful  individuals.  This  region  has  a  cutaneous  and  peritoneal 
face  ;  the  first  presents  on  the  median  line  a  raphe,  and  on  the  sides 
an  elongated  prominence  j  this  is  the  projection  of  the  posterior  verte- 
bral muscles ;  this  face  is  convex  transversely  and  is  concave  from 
above  downward,  and  more  so  in  the  female  than  the  male.  The 
second  is  convex  in  every  direction,  and  owes  this  arrangement  to  the 
curve  of  the  spine,  which  may  sometimes  be  felt  through  the  anterior 
wall  of  the  telly ;  most  of  the  abdominal  viscera  rest  against  it.  Far- 
ther, the  peritoneum  adheres  to  it  but  very  slightly  ;  it  is  separated  from 
it  by  much  cellular  tissue  and  by  the  kidney. 

Structure.  —  1.  Elements.  This  region  is  formed  very  naturally  ; 
its  skeleton  is  the  lumbar  portion  of  the  spine,  which  forms  most  of  it ; 
the  layers  of  the  vertebra,  nvhich  are  not  interlaced,  show  the  yellow 
ligaments ;  the  spinous  processes  are  long,  horizontal,  and  their  summits 
are  directly  under  the  skin  ;  the  upper  articular  processes  are  enlarged 


• 

'••*'* 

192       ,  TOPOGRAPHICAL    ANATOMY. 

by  a  kind  of  accessory  transverse  process.  The  vertebral  canal  is 
narrow,  and  the  inter-vertebral  foramina  are  very  broad  ;  it  contains 
a  cluster  of  nerves,  which  go  toward  the  lower  extremities  and  to  the  • 
pelvis;  The  muscles  may  be  divided  into  intrinsic  and  extrinsic :  the 
first  are  the  lumbar  inter-transverse  and  the  quadratus ;  among  the 
second,  we  mention  the  sacro-spinalis,  which  at  this  height  has  only  two 
fasciculi  j  first,  the  mass  of  the  sacro-lumbalis  and.  the  latissimus  dbrsi ; 
second,  the  semi-spinalis  dorsi,  a  muscle  which  is  named  improperly, 
as  it  is  not  attached  to  the  transverse  processes,  but  to  the  tubercles  of 
the  upper  articular  processes  :  we  also  mention  the  serratus  posticus 
superior,  and  the  two  psoas  muscles  ;  the  latissimus  dorsi  and  the 
diaphragm  also  enter  somewhat  into  the  structure  of  the  lumbar  region  j 
the  diaphragm  contributes,  hoxvever,  -only  by  its'  pillars. 

The  aponeuroses  are  more  numerous  and  stronger  in  the  loins  than 
in  any  other  part  of  the  body.  They  all  belong  to  the  muscles  ;  that 
of  the  transversalis,  single  on  the  outside  of  the  region,  •  it.  is  there 
divided  into  three  distinct  layers  ;  the  anterior  is  attached  to  the  base 
of  the  transverse  processes  of  the  region  ;  the  centre  is  inserted  in  the 
summit:  of  the  same  eminences. ;  finally,  the  third  in  the  spihous  pro- 
cesses ;  this  last  is  strengthened  by  the  aponeurosis  of  the  obliquus 
abdominis  externus  muscle,  and  by  that  of  the  latissimus  dorsi  and  the 
serratus  posticus  inferior  muscles. 

.  The  skin  is  here  remarkable  only  for  its  thickness,  which  is  greater 
than  on  the  anterior  wall,  and  by  its  slight  degree  of  sensibility,  it  pre- 
sents but  little  hair.  The  peritoneum  hardly  exists,  and  is  entirely 
accessory.  The  aorta  terminates  in  this  point,  sometimes  at  the  base  of 
the  region,  sometimes  a  little  above  it ;  sometimes,  but  rarely,  entirely 
above  it,  as  we  have  seen.  From  this  point,  it  sends  its  branches  from 
the  anterior  and  lateral  faces,  to  the  abdominal  viscera,  while  it  gives 
off;  from  its  posterior  face,  the  arteries  of  the  region,  the  lumbar,  which 
divide  into  an  anterior  and  posterior  branch  :  this  latter  belongs  par- 
ticularly to  the  vertebral  canal,  and  to  the  posterior  muscles  ;  this 
region  also  receives  some,  filaments  from  the  circumflex  iliac  artery, 
the  end  of  which  anastomoses  with  one  of  the  lumbar  arteries.  The 
lumbar  veins  follow  the  course  of  the 'arteries  exactly ;  like  them,  they 
communicate  with  the  renal  vessels  by  some  small  branches,  which 
come  from  the  latter,  and  are  distributed  to  the  external  fat  of.  the 
kidney.  All  go  into  the  vena  cava;  which  follows  the  cours£  of  the 
aorta,  and  differs  from  it  only  in  giving  off  no  intestinal  branches. 
The  anastomotic  origin  of  the  azygos  vein  belongs  to  this  region. 
The  lymphatic  vessels  are  superficial  and  deep;  the  first  go  into  the 
inguinal  ganglions,  and  some  into  those  of  the  axilla.  The  deep  ves- 
sels all  converge  toward  the  numerous  ganglions,  which  are  situated 


* 


LUMBAR  REGION.  193 

in  front  of  the  spine,  and  which  receive  with  the  lymphatic  vessels  of 
the  region  all  those  from  the  lower  parts  of  the  body,  and  also  those 
of  the  testicles  or  ovary.  All  these  vessels  unite,  and  form  the  com- 
mencement of  the  thoracic  duct,  which  is  often  dilated,  and  constitutes 
the  reservoir  of  Pecquet,  which  is  much  more  frequent  than  authors 
admit. 

There  are  two  orders  of  nerves  here;  the  tri -splanchnic  nerve  pre- 
sents here  its  lumbar  portion,  composed  of  five  ganglions,  and  of 
superior^  inferior,  external  and  internal  filaments ;  we  also  find  here 
the  solar  plexus  before  the  lumbar  portion  of  the  aorta,  and  the  lumbar 
nerves,  when  they  emerge  from  the  intervertebral  foramina :  their 
anterior  branches  form  by  an  angular  union  the  lumbar  plexus. 
Farther,  they  leave  also  some  filaments  in  the  posterior  layer  of  the 
union,  through  which  the  last  intercostal  nerve  and  the  ilio-scrotal 
nerve  pass  diagonally.  Much  cellular  and  adipose  tissue  exists  in  the 
loins  and  the  side  of  the  belly,  and  but  little  posteriorly,  beyond  the 
transverse  processes. 

We  find,  also,  in  this  region,  the  testicular  vessels,  or  those  of  the 
ovary. 

2.  Relations.  In  proceeding  from  behind  forward,  from  the  skin 
toward  the  peritoneum,  the  relations  of  the  lumbar  organs  are  the 
following :  first,  the  skin,  lined  by  a  dense  cellular  layer,  which 
attaches  it  very  intimately  in  the  centre  to  the  supra-spinal  lumbar 
ligament ;  second,  a  cellular  layer,  slightly  fatty  particularly  at  the 
median  line,  which  is  depressed  in  a  direct  ratio  with  the  en  bon  point 
of  the  individual ;  third,  the  origin  of  the  latissimus  dorsi  muscle, 
blending  with  the  serratus  posticus  inferior  muscle,  which  lies  under 
it ;  fourth,  an  aponeurosis,  formed  by  the  union  of  that  of  the  obliquus 
internus  and  the  posterior  fold  of  the  transversalis  muscle ;  fifth,  the 
mass  of  the  sacro-lumbalis  and  the  longissimus  dorsi,  with  the  semi- 
spinalis  dorsi  muscle,  situated  on  the  inside  and  below  ;  between  them, 
some  branches  of  vessels  and  nerves ;  sixth,  a  plane,  formed  by  the 
transverse  processes,  the  intertransversarii  muscles,  the  central  fold  of 
,  the  aponeurosis  of  the  transversalis^  and  the  layers  of  the  vertebrae, 
which  show  the  yellow  ligaments  ;  seventh,  the  quadratus  lumborum 
muscle,  and  the  ilio- lumbar  ligament;  eighth,  the  very  thin  anterior 
fold  of  the  aponeurosis  of  the  transversalis  muscle  ;  between  this  and 
the  preceding  muscle,  the  anterior  branch  of  the  last  lumbar  nerve 
and  of  the  ilio-scrotal  nerve,  with  some  considerable  vascular  branches  ; 
ninth,  on  the  outside,  the  kidney,  with  the  adipose  mass  which  sur- 
rounds it ;  on  the  inside,  the  psoas  magnus  muscle,  between  the  fas- 
ciculi of  which  the  lumbar  plexus  is  situated ;  between  this  same 
muscle  and  the  bodies  of  the  vertebrae,  some  osseous  and  fibrous  canals2 

25 


194  TOPOGRAPHICAL  ANATOMY. 

in  which  glide  the  arteries,  veins,  the  deep  lymphatics  of  the  loin,  and 
the  anastomotic  filaments  of  the  great  sympathetic  nerve  ;  when  the 
psoas  parvus  muscle  exists,  it  is  situated  on  the  outside  and  in  front 
of  the  psoas  magnus,  with  the  ureter  and  the  spermatic  vessels  ; 
tenth,  from  the  skin  to  the  peritoneum,  the  spine  separates  the  right 
and  left  parts  of  the  region/  which  are  perfectly  similar  on  both  sides  ; 
here,  the  convex  part  of  this  osseous  frame  forms  an  anterior  layer, 
before  which  are  situated  the  pillars  of  the  diaphragm,  on  the  right 
the  vena  cava,  on  the  left  the  aorta,  entirely,  on  the  outside,  the  great 
sympathetic  nerve,  above,  the  origin  of  .the  thoracic  canal  and  of  the 
azygos  vein,  and  farther  forward,  the  lumbar  lymphatic  ganglions  and 
much  loose  cellular  tissue. 

Development.  The  median  raphe  indicates  sufficiently  the  develop- 
ment of  this  region,  by  two  lateral  parts,  primitively  distinct,  and  united 
at  a  later  period  on  the  median  line  ;  the  spine,  particularly,  presents 
this  arrangement  in  a  very  marked  degree  ;  its  posterior  parts  are  not 
completely  formed  at  the  period  of  birth. 

Varieties.  In  the  female,  this  region  presents  a  greater  curve  than 
in  the  male  ;  numerous  individual  varieties  are  also  seen. 

Pathological,  and  operative  deductions.  The  loins  curve  laterally 
in  persons  affected  with  rachitis  ;  and  what  is  also  remarkable,  on  the 
side  opposite  to  that  of  the  deviation  in  the  thorax.  In  market  women, 
this  region  curves  much  more  than  in  the  normal  state.  Spina  bifida 
often  appears  here  ;  the  development  of  the  whole  "spinal  region,  and 
particularly  of  this  region,  explains  this  phenomenon.  Wounds  in  the 
loins,  if  made  by  a  pointed  instrument,  may  penetrate  into  the  vertebral 
canal,  between  the  layers  of  the  vertebrae,  and  may  cause  severe  symp- 
toms. The  superficial  position  of  the  spinous  processes  explains  their  fre- 
quent fractures,  and  also  those  of  the  layers  caused  by  a  counterblow. 
Fractures  of  the  skeleton  of  the  lumbar  region  paralyze  only  the  lower 
extremities  and  the  organs  contained  in  the  pelvis,  a  phenomenon 
connected  with  the  distribution  of  the  lumbar  nerves,  Moxas  should 
not  be  applied  in  this  region,  if  we  wish  to  act  directly  on  the  medulla, 
which  in  fact  terminates  at  its  upper  limit.  J.  L.  Petite  has  seen  one 
case  of  lumbar  hernia  ;  M.  J.  Cloquet  also  mentions  a  case  of  it.  The 
less  degree  of  resistance  between  the  limits  of  the  obliquus  externus 
and  the  latissimus  dorsi,  accounts  for  the  formation  of  this  lumbar 
tumor  ;  renal  urinary  fistula?  may  exist  in  the-  lumbar  region,  a'  little 
on  the  outside.  Abscesses  in  this  part  are  not  rare  ;  sometimes  they 
are  phlegmonous,  sometimes  they  depend  on  a  disease  of  the  skeleton 
of  the  region  ;  the  first  may  be  situated  in  all  the  cellular  spaces  under 
the  skin,  in  the  sheath  of  the  sacro-spinalis  muscle,  or  in  that  of  the 
quadratus,  around  the  kidney,  &c.  Of  the  abscesses  of  the  second 


LUMBAR  REGION.  195 

kind,  some  are  situated  necessarily  at  the  posterior  part  of  the  region, 
and  are  seen  in  this  direction,  if  the  layers  of  the  spihous  processes,  or 
the  processes  themselves,  are  affected  ;  in  these  cases,  the  central  fold 
of  the  aponeurosis  of  the  rransversalis  always  prevents  the  pus  from 
going  forward  j  other-  abscesses,  .which  result  from  the  alteration  of 
the  bodies  of  the  lumbar  vertebrae,  cannot,  for  this-reason,  go  backward, 
and  the  pus  descends  along  the  psoas  muscle,  when  the.  disease  of  the 
vertebrae  is  situated  at  the  level  of  the  muscle,  sometimes  continuing  out 
of  its  sheath,  and  following  the  femoral  vessels,  when  the  sub-aortic 
part  of  the  vertebras  is  carious.  The  operation  of  nephroioniy,  and 
also  that  for  artificial  anus,  as  proposed  by  Callisen  of  Copenhagen, 
must  always  be  proscribed,  on  account  of  the  thickness  of.  this  region, 
and  particularly  the  large  nerves  and  vessels,  which  must  be  divided 
to  perform  them.  In  this  region,  Cooper  has  tied  the  aorta ;  but  he 
divided  the  anterior  wall  of  the  abdomen  on  the  median  line ;  in  the 
cadaver,  the  aorta  may  be  tied  without  opening  the  peritoneum,  by 
making  an  incision  perpendicular  to  the  loins,  on  the  outside  of  the 
sacro-spinalis  muscle.  This  mode  of  operating  on  the  living  subject 
is  more  objectionable  than  nephrotomy,  and  hence  it  should  be  rejected. 
Farther,  the  ligature  of  the  aorta  is  also  a  very  serious  operation,  not 
because  it  prevents  the  circulation  in  the  lower  extremities,  for  this  is 
remedied  by  the  collateral  circulation,  but  because  it  cannot  be  per- 
formed without  opening  the  peritoneum,  and  consequently  without 
.giving  rise  to  peritonitis,  which  may  be  fatal ;  finally,  because,  as  the 
ligature  cannot  be  placed  except  below  the  very  large  collateral  arteries, 
the  lumbar  and  intestinal  arteries,  a  fatal  hemorrhage  would  inevitably 
ensue  upon  its  removal.  Ligatures  of  the  aorta  may  be  successful  in 
dogs,  but  should  not  be  adduced  in  favor  of  this  operation  in  man; 
we  know,  in  fact,  that  in  these  animals,  hemorrhages,  in  consequence 
of  arterial  ligatures,  rarely  occur,  and  peritonitis  is  much  less  serious. 
Engorgements  of  the  lumbar  ganglions,  which  may  be  felt  by  pressing 
the  abdomen  anteriorly,  may  arise  from  diseases  of  the  lower  extremi- 
ties, of  the  testicles,  or  of  the  pelvic  organs.  Masses  of  different  cha- 
racters, which  may  be  seated  in  the  ganglions,  sometimes  surround 
the  aorta,  and  vena  cava,  and  impede  the  circulation  in  the  lower 
extremities.  The  vascular  relations  between  the  kidneys  and  the 
lumbar  region,  explain  the  efficacy  of  leeches  applied  in  this  point  for 
nephritis,  &c. 


186  TOPOGRAPHICAL  ANATOMY. 


2.      ILIAC      REGION. 

It  is  composed  of  the  parts  which  rest  on  the  internal  iliac  fossa,  and 
may  be  described  hereafter  when  speaking  of  the  haunch ;  it  is  bound- 
ed very  naturally  by  the  spine,  the  iliac  crest,  and  the  crural  arch. 
This  region  presents  only  a  single  loose  face,  the  peritoneal,  which  is 
concave  and  which  supports  the  caecum  on  the  right  and  the  sigmoid, 
flexure  of  the  colon  on  the  left ;  its  surface  may  be  felt  by  depressing 
the  anterior  abdominal  wall. 

Structure.  —  \>  Elements.  The  skeleton  of  this  section  of  the  pos- 
terior abdominal  wall  is  represented  by  the  internal  iliac  fossa,  which  is 
thinner  in  the  centre  than  in  any  other  part.  The  iliacus  muscle- 
should  be  considered  as  the  special  muscle  ;  it  fills  the  region  and  pre- 
serves its  form  ;  the  psoas  magnus,  and  psoas  parvus  when  it  exists, 
are  also  situated  there,  in  a  part  of  their  course.  The  preceding  organs 
are  kept  against  the  skeleton  by  a  very  strong  aponeurosis,  which 
forms  a  complete  sheath  for  them :  this  aponeurosis  is  termed  the  iliac 
fascia ;  it  is  attached  above  on  the  ilio-lumbar  ligament  and  on  the 
inner  lip  of  the  iliac  crest,  on  the  inside  to  the  margin  of  the  upper 
strait  of  the  pelvis ;  it  is  continuous  with  the  outer  third  of  the  crural 
arch,  and  at  the  same  point  with  the  fascia  transversalis  ;  it  is  united 
under  the  crural  arch  with  the  deep  layer  of  the  fascia  lata,  which  is 
continuous  with  it ;  in  this  place  also,  it  is  strengthened  by  the  expan- 
sion of  the  tendon  of  the  psoas  parvus  muscle.  Its  two  faces  adhere 
but  slightly.  It  is  stronger  at  the  iliacus  muscle,  and  weaker  at  the 
psoas  muscle.  This  internal  iliac  sheath  is  perfectly  closed  upward, 
outward,  and  inward  ;  it  is  continued  to  the  thigh  by  the  fascia  lata, 
and  terminates  in  a  point  near  the  small  trochanter.  The  peritoneum 
of  this  region  is  very  dense  ;  it  adheres  slightly.  The  arteries  come 
from  the  circumflex  iliac,  from  the  last  lumbar,  and  from- the  ilio-lum- 
bar artery.  The  first  two  form  an  important  anastomotic  arch  on  the 
iliac  crest ;  the  third  is  distributed  in  the  centre  of  the  region.  The 
primitive  iliac  artery  and  the  external  which  continues  it,  are  situated 
on  the  inner  limit  of  this  region,  and  it  usually  gives  off  the  epigastric 
and  the  circumflex  iliac  artery,  on  leaving  the  region.  The  veins 
follow  the  arteries  exactly ;  we  must  however  remark,  that  the  iliac 
vein,  on  entering  at  the  lower  part  of  the  region,  receives  from  the  sub- 
pubic  foramen  a  large  vein,  which  represents  the  course  of  the  obtura- 
tor artery  when  it  comes  from  the  epigastric  or  from  the  external  iliac 
artery.  A  body  of  ganglions  occupies  the  internal  part  of  the  region 
accompanying  the  external  iliac  artery ;  these  ganglions  receive  the 


ILIAC  REGION.  197 

vessels  from  the  whole  corresponding  lower  extremity  and  those  of  the 
region.  The  nerves  come  from  the  lumbar  plexus,  some  of  them,  how- 
ever, only  pass  through  it  and  give  off  no  branches  ;  the  crural  and  the 
genito-crural  proceed  perpendicularly,  the  inguino-cutaneous  branches 
obliquely  outward.  Adipose  tissue  exists  there  only  superficially,  and 
in  small  quantities ;  the  cellular  tissue  is  very  loose  in  every  part. 

2.  Relations.  In  reviewing  the  iliac  region  we  find,  under  the 
peritoneum  and  the  intestines  which  it  confines,  a  very  loose  cellular 
and  adipose  layer ;  on  the  inside,  in  the  course  of  a  line  drawn  from 
the  umbilicus  to  the  centre  of  the  crural  arch,  the  primitive  and  ex- 
ternal iliac  arteries,  having  at  their  inner  and  lower  part  their  attendant 
vein  covered  by  some  lymphatic  ganglions ;  second,  the  fascia  iliaca 
aponeurosis  which  forms  a  layer  moulded  on  the  following  ;  third,  the 
iliacus  and  psoas  muscles  on  the  inside,  forming  a  layer  which  is 
slightly  elevated,  on  which  we  observe  an  angle  where  the  crural 
nerve  is  situated  ;  we  also  find  directly  before  these  muscles  the  genito- 
crural  nerve  on  the  inside,  the  inguino-cutaneous  nerve  on  the  outside  ; 
most  of  the  vessels  also  lie  under  the  aponeurosis ;  the  anastomotic 
arch  mentioned,  and  particularly  the  circumflex  artery,  are  situated  in 
a  small  sheath  formed  by  the  doubling  of  the  iliac  fascia.  The  branch 
of  the  ilio-lurabar  artery  at  its  origin  passes  under  the  psoas  muscle. 
All  these  sub-aponeurotic  parts  are  united  by  a  very  loose  cellular 
tissue. 

Development.  For  a  long  time  this  region  is  rudimentary,  when 
compared  with  the  rest  of  the  abdominal  parietes.  It  does  not  acquire 
its  proportional  extent  until  after  birth,  and  at  the  period  of  puberty ; 
at  this  time  it  enlarges  transversely  in  the  young  girl,  while  in  the  boy, 
its  vertical  extent  predominates. 

Varieties.  The  arterial  trunk  which  passes  through  this  region 
varies  much ;  in  fact,  this  vessel  sometimes  gives  off  the  obturator  artery, 
sometimes  near  the  crural  arch,  sometimes  more  or  less  above,  and  rarely 
below  it.  The  epigastric  and  circumflex  arteries  may  also  arise  unusu- 
ally high.  We  sometimes  find  in  this  region  an  abnormal  muscular 
fasciculus,  which  terminates  on  the  common  tendon  of  the  psoas  and 
iliacus  muscles. 

Pathological  and  operative  deductions.  The  iliac  region  may  be 
entirely  deficient  with  its  corresponding  limb ;  its  slow  development 
explains  this  monstrosity.  Instruments  which  wound  this  region  must 
affect  the  anterior  abdominal  wall.  If  they  penetrate  internally,  they 
may  mortally  wound  the  external  iliac  artery ;  external  wounds  are 
always  less  serious.  In  operations,  the  surgeon  may  arrive  at  this  part 
of  the  abdomen  in  a  similar  manner.  Thus  Duret  has  formed  here  an 
artificial  anus,  in  a  child  where  the  rectum  was  deficient,  by  bringing 


198  TOPOGRAPHICAL    ANATOMY. 

outward  the  sigmoid  .flexure  of  the  colon  ;  he  seems  to  have  opened 
the  peritoneum.  This,  however,  may  be  avoided,  by  operating  on  the 
posterior  face  of  the  intestine,  and  opening  it  in  that  part,  where  it  has 
no  serous  membrane.  The  ligature  of  the  external  iliac  artery  also 
belongs  to  this  region.  The  primitive  iliac  artery  has  also  been  tied 
in  the  same  point,  and  a  ligature  has  been  applied  successfully  to  the 
hypogastric  artery  by  Dr.  Stevens.  -Our  remarks  on  the  anterior  ab- 
dominal wall,  imply  the  necessity  in  these- operations  of  making  inci- 
sions oblique  from  the  groin  towards  the  flank,  without  approaching 
too  near  the  iliac  crest ;  this  has  been  the  mode  followed  by  those 
skilful  surgeons  who  have  performed  the  operations  mentioned,  and 
first  by  Abernethy.  In  this  manner,  we  operate  between  the  epigas- 
tric and  circumflex  arteries  which  are  avoided,  and  particularly  on  ar- 
riving at  the  peritoneum  at  its  point  of  reflection;  it  is  easily  separated 
from  the  iliac  fascia  to  which  it  slightly  adheres  ;  we  may  then  touch 
the  artery  on  the  inside  of  the  region,  which  must  be  raised  from  within 
outward,  to  avoid  taking  its  attendant  vein,' which  is  situated  on  the  in- 
side ;  the  crural  nerve  is  no  obstruction,  it  is  separated  from  the  vessels 
by  the  psoas  muscle  and  enclosed  in  its  sheath.  In  order  that  the  liga- 
ture, of  the  external  iliac  artery  may  succeed,  it  must  not  be  applied 
directly  below  the  origin  of  the  circumflex  and  epigastric  arteries,  in 
conformity  to  the  general  rule  in  tying  the  arteries;*  the  varieties  in 
these  vessels  prqbably  account  for  the  number  of  unsuccessful  ope- 
rations. In  order  to  be  more  certain  of  tying  the  external  iliac  artery 
in  the  place  we  wish,  we  may  follow  the  ingenious  process  of  Bogros, 
which  consists  in  dividing  the  abdominal  wall  according  to  the  course 
of  the  crural  arch  near  its  middle  third,  so  as  to  cut  successively ;  the 
skin,  the  fascia  superficialis,  the  aponeurosis  of  the  obliquus  externus, 
after  which  we  come  to  the  spermatic  cord  or  the  round  ligament,  the 
united  edge's  of  the  obliquus  internus  and  transversalis  muscles,,  we 
separate  .the  fascia  transversalis,  and  then  by  following  the  epigastric 
artery,  which  is  seen  in  the  course  of  the  wound,  we  cannot  fail  of 
coming  to  the  iliac  artery.  Cooper's  method  resembles  this  a  little  ; 
he  makes  a  curved  incision.  Farther,  this  operation  would  still  be 
insufficient  to  tie  the  iliac  artery  above  the  epigastric  artery,  in  a 
variety  where  this  vessel  arose  unusually,  high.  Abscesses  are  frequent 
in  the  iliac  region;  they  are  idiopathic  or  symptomatic;  the  pus 
which  then  forms,  always  points  towards  the  thigh.  Idiopathic  ab- 
scesses may  exist  under  the  aponeurosis  .or  peritoneum  ;  this  is  true 
also  of  abscesses  by  congestion ;  the  latter  do  not  present  the  first 
character,  except  when  caries  affects  the  ilium,  or  the  sides  of  the  lum- 

*  An  artery  should  be  tied  as  far  as  possible  below  a  collateral  branch. 


GROIN.  199 

bar  vertebrae  ;  in  other  cases,  they  are  situated  under  the  peritoneum. 
The  sub-peritoneal  abscesses  of  the  iliac  fossa  do  not  affect  its  muscle, 
and  point  toward  the  thigh  on  the  inside  and  in  front  of  the  femoral 
vessels.  The  sub-aponeurotic  abscesses  point  in  the  iliac  sheath,  and 
near  the- small  trochanler,  on  the  outside  of  the  -femoral  vessels,  and 
burrow  through  or  destroy  the  muscles  of  this  region. 


OP. THE       GROIN. 

The  iliac  region  Unites  with  (he  anterior  abdominal  Wall,  and  forms 
'an  angle,  open  on  the  side  of  the  belly,  and  extending  from  the  anterior 
and  superior  spine  of  the  ilium -to  the  .pubis,  near  which,  also,  the 
pelvic  limb  joins  these  two  regions  :  this  is  the  groin.  This  region  is 
marked  externally  by  an  oblique  fold,  from  the  flank  to  the  pubis,  and 
is  very  distinct  in  fat  individuals,  and  while  the  corresponding  limb  is 
flexed.  The  skin  is  hairy  in  that  part,  and  the  hand  readily  perceives 
under  it  some  small  prominences,  which  are  the  superficial  inguinal 
ganglions. 

Structure.  The  anterior  edge  of  the  iliac  bone  forms  the  skeleton 
of  this  region ;  it  presents  two  anterior  iliac  spines,  separated  by  a 
fissure,  the  groove  of  the  psoas  and  iliacus  muscles,  the  ilio-pectmeal 
eminence,  the1  crest  of  the  pubis,  and  the  triangular  surface,  belonging 
to  the  pectineus  muscle,  the  spine  of  the  pubis,.  and  a  surface  which 
contributes  to  form  the  inguinal  ring.  This  great  fissure  is  changed 
into  a  foramen  by  the  crural  arch,  (the  reflected  edge  of  the  aponeurosis 
of  the  obliquus  externus  muscle.)  The  latter  is  attached  very  simply 
on  the  iliac  spine. and  the  pubis ;  it  is  separated  into  two. fasciculi, 
mentioned  above ;  its  lower  edge  is  continuous,  on  the  outside,  with 
the  entire  fascia  lata,  on  the  inside,  with  its  superficial  layer  only ;  its 
posterior  edge  is  reflected  upwards,  and  is  continuous  in  its  external 
third  with. the  fascia  iliaca ;  in  its  middle  third,  with  the  fascia  trans- 
versalis ;  and  in  the  internal  third,  it  is  attached  to  the  crest  of  the 
pubis,  and  thus  forms  Gimbernat's  ligament,  which  has  an  upper  and 
anterior  face,  and  a  posterior  and  inferior  face.  Gimbernat's  ligament 
is  attached  by  one  of  its  edge's  on  the  crest  of  the  pubis,  and  by  the 
other  on  the  crural  arch ;  this  latter,  which  is  the  base  of  the  triangle 
represented  by  this  part,  is  concave,  and  turned  outward.  In  conse- 
quence of  this  arrangement,  the  opening  formed  by  the  crural  arch 
with  the  iliac  fissure  is  loose  only  in  the  centre,  and  represents  a  tri- 
angular ring;  the  anterior  edge  of  which  is  formed  by  the  crural  arch, 
the  posterior  by  the  horizontal  ramus  of  the  pubis,  and  the  external  by 
the  sheath  of  the  psoas  and  iliacus  muscles,  strengthened  in  this  point 


200  TOPOGRAPHICAL  ANATOMY. 

by  an  expansion  of  the  psoas  parvus  muscle ;  the  inner  angle  of  this 
ring  is  blunt,  and  occupied  by  Gimbernat's  ligament ;  the  posterior 
includes  the  femoral  vessels,  while  the  external  is  unimportant. 

If  we  now  examine  the  relations  of  this  opening,  we  find  that  its 
anterior  edge  is  covered  from  within  outward  by  the  skin,  the  fascia 
superficialis,  the  sub-cutaneous  abdominal  artery,  some  lymphatic 
ganglions,  to  which  the  superficial  lymphatic  vessels  proceed  from  the 
genital  organs,  from  the  corresponding  limb,  and  from  the  lower  part 
of  the  abdominal  wall :  in  this  anterior  edge  we  find,  finally,  the 
inguinal  canal,  and  also  the  spermatic  cord,  or  the  round  ligament. 
The  posterior  edge  is  formed  by  the  horizontal  ramus  of  the  pubis, 
covered  by  the  pectineus  muscle,  which  conceals  anteriorly  the  deep 
layer  of  the  fascia  lata.  Finally,  the  epigastric  vessels  are  situated 
near  the  outside,  and  in  the  sheath  which  forms  this  wall  of  the  crural 
opening ;  we  find  from  within  outward,  the  crural  nerve,  the  psoas 
and  the  iliacus  muscles,  and  the  inguino-cutaneous  nerves,  situated 
between  the  two  iliac  spines.  This  triangular  opening  of  the  groin  is 
closed  by  a  cellular  layer,  which  Cloquet  proposes  to  call  the  crural 
septum  :  it  is  the  propria  fascia  of  some  writers.  This  layer  is  of  little 
importance,  and  adheres  to  nearly  all  the  edge  of  the  opening :  the 
peritoneum  is  separated  from  it  by  a  triangular  space,  formed  by -the 
place  where  it  is  reflected  to  go  from  the  anterior  wall  of  the  abdomen 
to  the  iliac  fossa.  On  the  side  of  the  thigh  this  opening  is  continuous 
with  an  interstice  which  we  shall  describe  hereafter,  of  which  it  forms 
the  upper  orifice ;  this  is  the  crural  canal,  which  is  of  but  little  im- 
portance compared  with  the  opening  of  which  we  are  speaking.  This 
true  foramen  contains  the  femoral  vessels  in  its  posterior  and  external 
angles,  the  vein  on  the  inside  of  the  artery ;  near  Gimbernat's  ligament, 
a  large  lymphatic  ganglion  always  exists,  and  often  another  before  the 
crural  vessels,  with  a  plexus  of  deep  lymphatic  vessels,  which  go  to 
the  iliac  ganglions.  The  cellular  tissue  contained  is  very  loose,  and 
but  little  fat  exists  there. 

Varieties.  In  the  female,  this  opening  is  greater  transversely  than 
in  the  male,  as  it  is  more  flaring.  In  the  normal  state,  the  crural 
opening  on  the  outside  is  near  the  epigastric  artery,  anteriorly,  the 
inguinal  canal  and  the  parts  which  it  contains ;  the  femoral  vessels 
rest  on  the  external  posterior  part,  and  we  find  only  a  small  vessel 
behind  Gimbernat's  ligament:  sometimes,  on  the  contrary,  a  very 
large  artery,  (the  sub-pubic  or  obturator  artery,)  arises  in  this  point 
from  the  epigastric  artery,  and  then  the  whole  circumference  of  the 
opening  is  contiguous  to  remarkable  vessels,  except  its  posterior  and 
internal  part,  which  is  bony;  the  obturator  artery  arises  from  the 
epigastric  artery  once  in  ten  times ;  but  the  relations  of  theise  two 


GROIN.  201 

vessels  at  their  origin  are  rarely  such  that  the  obturator  artery  passes 
on  the  external  or  concave  edge  of  Gimbernat's  ligament ;  in  order 
that  this  may  occur,  this  vessel  must  come  from  the  epigastric  artery 
about  an  inch  below  the  origin  of  this  from  the  iliac.  When  the  dis- 
tance is  less,  the  obturator  artery  descends  directly  toward  the  sub- 
pubic  foramen,  and  does  not  touch  Gimbernat's  ligament;  when,  on 
the  contrary,  the  distance  is  greater,  and  this  is  rare,  it  descends  toward 
the  obturator  foramen,  and  is  situated  far  from  the  base  of  this  liga- 
ment, and  has  no  relations  with  the  anterior  side  of  the  ring,  the  crural 
arch-. 

Pathological  and  operative  deductions.  The  diseases  which  ap- 
pear in  the  groin  may  be  situated  in  the  crural  opening^  or  on  the 
outside,  in  the  parts  around  it. 

The  abdominal  viscera  often  descend  into  the  crural  canal,  enve- 
loped with  the  herniary  sac ;  this  is  crural  hernia,  which  is  more 
frequent  in  the  female,  on  account  of  the  greater  size  of  the  crural 
opening  compared  with  that  of  the  inguinal  canal.  The  neck  of  the 
sac  of  the  femoral  hernia  generally  has  the  epigastric  vessels  on  its 
outside ;  J.  Cloquet,  however,  cites  a  case,  where  the  hernia  occurred 
on  the  outside  of  them,  through  an  erosion  of  the  fascia  iliaca  aponeu- 
rosis.  The  herniary  parts  descend  before  and  on  the  inside  of  the  crural 
vessels,  push  before  them  the  crural  septum,  which  they  break  after 
it  has  been  distended  ;  these  hernias  are  enveloped  by  different  layers, 
which  are  covered  by  the  crural  ring,  the  skin,  the  fascia  superficialis, 
the  crural  arch,  and  the  layer  of  the  fascia  lata  which  adheres  to  it  at 
its  commencement ;  finally,  the  crural  septum  is  also  doubled  around 
the  herniary  sac,  which  comes  next.  The  relations  of  the  neck  of 
the  sac  with  the  vessels  are  the  same  as  those  of  the  opening ;  hence, 
we  can  imagine  why  Scarpa  advises  to  cut  inward  upon  Gimbernat's 
ligament ;  the  abnormal  position  on  this  of  the  obturator  artery  should 
induce  us  to  adopt  the  advice  given  by  Petite,  to  use  a  bistoury  a  la 
lime,  an  instrument  which  will  cut  the  ligament,  but  which  only 
crowds  back  the  artery,  which  is  attached  but  loosely ;  an  incision 
upward  and  outward  does  not  expose  the  obturator  artery,  when  an 
anomaly  exists,  more  than  the  preceding ;  it  is  more  advantageous 
than  that  which  is  made  anteriorly,  because  we  are  less  liable  to  injure 
the  spermatic  cord,  or  the  round  ligament.  Farther,  in  making  the 
incision  in  crural  hernia,  in  the  manner  Dupuytren  advises,  we  must 
not  forget  that  we  cut  very  near  the  epigastric  artery.  A  false  or  true 
aneurism  may  arise  from  the  artery  situated  in  this  point.  The  con- 
tiguity of  the  artery  and  vein  shows,  a  priori,  the  possibility  of  a 
varicose  aneurism  in  this  point ;  we  have  seen  two  cases  of  it.  The 
pus  of  abscesses  of  the  iliac  region  points  in  the  crural  opening,  if  it 

26 


202  TOPOGRAPHICAL    ANATOMY. 

be  formed  under  the  peritoneum  ;  that  which  results  from  the  caries 
of  the  bodies  of  the  lumbar  vertebrae  anteriorly,  also  comes  there,  but 
follows  the  iliac  vessels. 

2.  Oh  the  outside  of  the  crural  opening,  we  often  find  engorgements 
of  different  natures  of  the  superficial  ganglions,  idiopathic  or  sympto- 
matic engorgements  ;  tumors  of  the  inguinal  canal,  also,  are  referred 
to  this  point,  and  have  sometimes  been  taken  for  diseases  situated  in 
the  crural  opening.  On  the  outside,  in  the  sheath  of  the  psoas  and 
iliacus  muscles,  we  often  find  pus,  which  burrows  through  these 
muscles,  and  descends  toward  the  small  trochanter ;  pus  may  be 
formed  there,  or  may  come  from  the  iliac  and  lumbar  regions. 
When  the  hip  is  dislocated  forward  and  upward,  the  head  of  the  bone 
raises  these  muscles  on  the  outside  of  the  vessels,  and  crowds  them  a 
little  back-  Exostoses  may  be  formed  on  the  horizontal  ramus  of  the 
pubis,  and  they  then  contract  the  opening  by  crowding  the  vessels 
forward.  All  the  tumors  situated  here  before  the  vessels,  and  those 
also  which  result  from  their  dilatation,  pulsate ;  in  the  former,  they 
are  simply  raised  ;  the  second  are  characterized  by  motions'  of  internal 
expansion. 


PARAGRAPH      THIRD. 


OF    THE    SUPERIOR    ABDOMINAL    WALL. 

This  portion  of  the  abdomen  is  formed  by  the  diaphragmatic  region, 
which  has  been  described  when  speaking  of  the  chest,  of  which  it 
forms  also  the  lower  wall. 


PARAGRAPH      FOURTH. 


OF    THE    INFERIOR   ABDOMINAL    WALL. 

This  wall,  which  includes  the  circumference  of  the  cavity  of  the 
pelvis,  forms  for  the  abdomen  a  floor,  concave  upward,  opposite  in 
every  respect  to  the  diaphragm.  It  is  composed  of  two  parts,  the 
perineum  and  the  pelvic  region. 


PERINEUM.  203 


ORDER      FIRST. 


OF    THE    PERINEUM. 


The  perineum  is  a  large  and  very  important  region,  formed  by  the 
group  of  organs  situated  in  the  area  of  the  inferior  strait  of  the  pelvis. 
It's  limits  are  the  same  as  those  of  this  strait ;  they  are  very  visible. 

Some  anatomists  confine  the  term  perineum,  in  its  etymological 
acceptation,  to  the  genital  region,  or  to  the  space  between  the  genital 
organs  and  the  anus  ;  but  we  give  it  a  broader  sense. 

The  perineum  presents,  according  to  the  sexes,  such  marked  diffe- 
rences, which  depend  on  those  of  (he  genital  organs,  that  we,  at  first, 
made  two  distinct  regions  of  it ;  but  more  mature  examination  demon- 
strated, that  the  elementary  parts,  and  also  the  whole  formed  by  their 
union,  are  very  analogous ;  we  shall,  therefore,  give  some  general 
remarks  on  the  perineum,  and  then  neglect  the  analogies,  and  attend 
solely  to  the  sexual  differences.  The  description  will  be  based  upon 
the  adult  age. 


1.'     GENERAL        REMARKS        ON        THE        PERINEUM 
CONSIDERED       IN       THE       TWO       SEXES. 

The.  extent  of  the  surface  of  the  perineum  is  estimated  by  drawing 
ah  antero-posterior,  a  transverse,  and  an  oblique  diameter  ;  they  vary 
much  according  to  the  sexes  ;  consequently,  their  length,  and  likewise 
the  .height  of  the  perineum,  which  dimension  must  be  estimated  in 
different  points,  cannot  be  mentioned  in  this  chapter. 

The  perineum  presents  two  faces,  one  cutaneous,  the  other  perito- 
neal ;  the  first  is  concave  transversely,  especially  at  the  sciatic  tube- 
rosities,  and  is  convex  from  before  backward  ;  it  appears  in  the  form 
of  a  longitudinal  groove,  on  which  the  median  raphe  is  very  distinct : 
we  find  there  the  terminating  openings  of  the  digestive,  urinary,  and 
genital  organs.  The  peritoneal  face  is  more  or  less  remote  from  the 
preceding,  and  presents  variable  peritoneal  depressions.  The  urinary, 
genital,  and  digestive  organs,  pass  through  the  perineum  in  curved 
lines. 

Structure.  —  \.  Elements.  This  region,  properly  speaking,  has  no 
skeleton  ;  it  is  only  circumscribed  by  some  bones  and  ligaments.  We 
find  there,  some  intrinsic  and  extrinsic  muscles ;  among  the  former  we 
must  mention  first  the  levator  ani ;  second,  the  sphincter,  which  termi- 
nates anteriorly  on  one  of  the  aponeuroses  of  the  perineum,  and  not,  as 


204  TOPOGRAPHICAL    ANATOMY. 

authors  say,  on  the  bulbo-cavernosus,  the  posterior  extremity  of  which 
muscle  also  differs  from  the  arrangement  generally  mentioned ;  in  fact, 
it  arises  posteriorly  from  the  inferior  aponeurosis  of  the  perineum ; 
third,  we  find  also  in  this  place  the  ischio-cavernosus,  and  fourth,  the 
transversus  perinei  muscle,  which  vary  much  in  their  existence,  and 
their  direction.  We  have  mentioned  here  the  bulbo-cavernosus  muscle, 
because  it  exists  in  the  female,  as  in  the  male,  with  this  difference 
however,  that  in  the  former  its  two  fasciculi  separate  to  embrace  the 
vulva,  while  in  the  second  they  unite  under  the  bulb  of  the  urethra- ; 
but  this  name  should  evidently  be  changed  in  this  general  description  ; 
that  of  ano-cavernosus  is  both  rnore  philosophical  and  more  conven- 
ient. The  glutaeus  maximus  muscle,  which  belongs  but  in  a  trifling 
degree  to  this  region,  is  extrinsic. 

The  skin  and  the  peritoneum  present  nothing  general  to  be  men- 
tioned in  this  place.  The  arteries  are  here  very  numerous  ;  they  come 
from  a  common  trunk  situated  on  the  bounds  of  the  region,  in  the 
parietes  of  the  pelvis  ;  this  is  the  internal  pubic,  which  rests  in  every 
part  against  the  inner  face  of  the  pubic  arch ;  the  branches  which  it. 
sends  off  in  the  perineum  are ;  first,  the  inferior  hemorrhoidal  artery, 
which  proceeds  transversely  towards  the  anus,  behind  the  sciatic  tu- 
berosities  ;  second,  the  superficial  perineal  artery,  which  comes  into 
this  region  a  little  before  the  sciatic  tuberosity,  and  proceeds  on  the 
outer  limits  of  the  perineum,  constantly  proceeding  toward  the  median 
line,  at  which  it  arrives  in  the  septum  of  the  dartos,  after  giving  off 
some  small  transverse  branches  toward  the  median  line  ;  third,  the 
transverse  or  urethral  artery,  the  direction  of  which  is  transverse,  be- 
fore the  sciatic  tuberosities,  which  varies  much  in  respect  to  its  origin 
and  direction  ;  in  fact  it  often  arises  near  the  tuberosity,  and  goes  ob- 
liquely toward  the  urethra.  The  veins  generally  follow  the  course  of 
the  arteries  ;  we  must  nevertheless  observe  that  the  hemorrhoidal  vein 
anastomoses  with  the  origin  of  the  small  mesaraic  vein,  by  filaments 
which  pass  through  the  fasciculi  of  the  sphincter  ani  muscle,  that  the 
superficial  perineal  vein  is  very  small  and  sometimes  deficient,  that  the 
trunk  of  the  pubic  vein  commences  in  the  corpus  cavernosum,  and  « 
does  not  receive  the  blood  from  its  dorsal  vein,  and  finally,  that  the  latter 
passes  near  the  root  of  the  penis,  under  the  pubic  arch,  and  contributes 
to  form  a  very  complex  net-work  around  the  neck  of  the  bladder. 
The  lymphatic1  vessels  are  superficial  or  deep ;  the  first  go  into  the 
inguinal  ganglions,  the  second  into  the  pelvis  and  into  the  hypogastric 
ganglions. 

The  nerves  of  the  perineum  nearly  follow  the  course  of  the  arteries  ; 
they  have  an  anal,  a  superficial  perineal,  and  a  deep  branch. 

The  perineum  presents  some  remarkable  aponeuroses.     Of  these 


PERINEUM.  205 

there  are  three,  each  forming  a  distinct^horizontal  layer,  a  superficial, 
a  middle,  and  an  inferior.  We  observe,  however,  that  the  inferior 
aponeurosis  is  deficient  posteriorly,  and  exists  only  in  the  triangular 
space,  bounded  by  the  branches  of  the  pubic  arch,  and  by  an  imaginary 
line  drawn  between  the  two  sciatic  tuberosities.  These  aponeuroses 
have  received  different  names ;  of  these  names  the  best  are  those  which 
convey  an  idea  of  their  position.  They  are  all  evidently  continuous, 
so  that  they  form  anteriorly  two  sheaths,  in  which  all  the  organs  are 
successively  situated. 

The  superior  aponeurosis  of  the  perineum,  (the  fascia  pelvia,  the 
recto-vesical  aponeurosis,)  occupies  the  base  of  the  pelvis  and  lines  its 
parietes ;  it  is  attached  on  the  sides  to  the  margin  of  the  pelvis,  where 
it  is  continuous  to  a  slight  extent  with  the  fascia  iliaca  ;  it  is  united 
anteriorly  to  the  posterior  face  of  the  pubis  and  of  its  horizontal  ramus ; 
posteriorly,  it  commences  on  the  anterior  face  of  the  sacrum,  in  front 
of  the  sacral  foramina ;  thence  it  descends  in  a  curve,  and  terminates  on 
the  rectum,  on  the  neck  of  the  bladder  and  the  genital  organs.  We 
may  describe  it  as  forming  a  floor,  concave  upward,  perforated  only  to 
give  passage  to  the  rectum,  the  genital  and  urinary  organs.  It  is 
more  dense  anteriorly,  where  it  forms  two  strong  folds,  inserted  on  the 
pubis  and  the  neck  of  the  bladder,  (the  anterior  ligaments  of  the  blad- 
der) between  which  are  openings,  through  which  pass  the  dorsal  veins 
of  the  erectile. organ.  At  the  infrapubic  foramen,  this  aponeurosis  forms 
an  arch,  on  which  the  obturator  nerves  and  vessels  rest ;  posteriorly, 
it  presents  a  foramen  for  the  passage  of  the  lumbo-sacral  nerve  and 
the  gluteal  vessels ;  and  another  through  which  pass  the  pudic  and 
sciatic  arteries  ;  it  touches  the  peritoneum  above,  below  it  rests  on  the 
levator  ani,  the  pyramidalis  and  the  obturator  internus  muscles,  the 
sacral  plexus  and  the  median  organs  of  the  perineum. 

The  middle  aponeurosis  of  the  perineum,  (the  aponeurosis  of  the  le- 
vator ani,)  the  perineal  ligament  of  Carcassomme,  who  saw  it  only 
anteriorly,  arises  on  the  outside  and  posteriorly,  from  the  outer  face  of 
the  preceding,  at  the  upper  edge  of  the  levator  ani  muscle,  and  is  in- 
serted in  the  angle  of  separation  ;  anteriorly  it  is  inserted  on  the  inter- 
stice of  the  branches  of  the  pubic  arch,  being  continuous  with  the 
inferior  pubic  ligament ;  it  goes  from  thence  on  the  sides  of  the  bulb 
of  the  urethra,  which  it  attaches  very  intimately  on  the  median  line, 
near  the  circumference  of  the  edge  of  the  anus,  extending  between  the 
digestive,  urinary,  and  genital  organs,  so  as  to  form  a  second  fibrous 
layer,  which  is  perforated  only,  like  the  superior  aponeurosis,  to  give 
passage  to  the  median  organs  and  to  some  nervous  and  vascular  fila- 
ments. There  is  always  a  foramen  under  the  symphysis  pubis  ;  the 
dorsal  veins  and  arteries  of  the  corpus  cavernosum  pass  through  it  in 


206  TOPOGRAPHICAL  ANATOMY. 

an  opposite  direction.  This  aponeurosis  is  very  strong  anteriorly  and 
very  feeble. posteriorly ;  its  superior  face  corresponds  to  the.levator 
ani  muscle,  the  inferior  and  external  gives  rise,  on  the  outside,  to  a 
very  strong  fibrous  layer,  which  descends  perpendicularly  on  the  sides 
of  the  pelvis,  and  consequently  out  of  the  region,  and  terminates  on  the 
inner  edge  of  the  great  sacro-sciatic  ligament ;  finally  an  aponeurotic 
layer,  which  retains  against  the  ramus  of  the"  ischium,  the  internal 
pudic  trunk  The  point  where  these  two  aponeuroses  separate  forms 
an  angle  open  downwards,  which  is  filled  by  cellular  tissue  and  fat 
The  inferior  or  superficial  perineal  aponeurosis  exists  only  before  a 
line  drawn  to  the  level  of  the  sciatic  tuberosities.  We  demonstrated 
this  several  years  since,*  and  it  was  drawn  in  our  plates ;  but  then 
we  did  not  know  .its  importance  and  connexions.  From  the  first  dis- 
section of  this  layer  its  description  was  necessarily  imperfect,  and  it  was 
proposed  to  call  it  the  ano-urethral.  We  can  now  speak  of  it  more 
in  detail ;  it  arises  in  front  of  the  anus,  between  the  sciatic  tuberosities, 
from  the  lower  face  of  the  preceding  aponeurosis  •  on  the  sides,  it  is 
attached  very  strongly  to  the  external  lip  of  the  pubic  arch;  it  is  con- 
tinuous anteriorly  with  the  dartos  muscle ;  it  has  the  triangular  form 
of  the  space  where  it  is  situated ;  it  is  dense  posteriorly  and  feebler 
anteriorly,  and  is  situated  under  the  skin,  as  if  to  separate  the  anus 
from  the  urinary  and  genital  organs.  In  man,  the  upper  face  of  this 
covers  the  bulb  of  the  urethra,  the  roots  .and  muscles  of  the  corpus 
cavernosum.  In  the  centre  of  this  face  are  inserted  the  bulbo-caver- 
nosus  or  ano-cavernosus  muscle,  and  the  inferior,  the  anterior  extremi- 
ty of  the  sphincter  ani  muscle. 

The  cellular  tissue  in  the  perineum  is  particularly  abundant  down- 
ward and  backward  ;  it  is  more  dense  on  the  median  line  than  in  other 
points.  A  great  quantity  of  fat  is  situated  particularly  around  the 
rectum  ;  we  find  but  little  or  none  between  the  inferior  and  middle  apo- 
neurosis: but  little  exists  under  the  perineum;  in  regard  to  continuity, 
these  tissues  must  be  separated,  into  four  layers  ;  the  first  is  sub-cuta- 
neous, the  second  is  .situated  between  the  inferior  and  middle  aponeu- 
rosis, the  third  between  the  middle  and  superior  aponeurosis,  finally, 
the  fourth  between  this  latter  and  the  peritoneum.  The  second  layer 

*  All  authors  mention  the  superficial  perineal  aponeurosis  ;  it  may  therefore  seem  singular 
that  this  part  is  described  here  as  something  new  ;  but  the  description  will  prove  this  to  be 
the  fact,  and  that  the'term,  inferior  perineal  aponeurosis,  has  hitherto  been  applied  to  the  sub- 
cutaneous tissue  of  the  perineum,  as  can  be  seen  in  Dupuytren's  splendid  plates  :  this  differs 
entirely  from  what  we  are  describing.  Farther,  what  is  generally  received  as  the  inferior 
perineal  aponeurosis  is  of  no  importance ;  this  is  not  the  case  with  that  of  which  we  are 
speaking.  Some  may  say  this  aponeurosis  is  an  appendage  of  the  fascia  superficial  of  the 
abdomen  ;  they  will  admit,  however,  that  the  perineal  arrangement  of  this  fascia  has  not  been 
mentioned. 


PERINEUM.  207 

is  separated  from  the  first  by  the  inferior  aponeurosis,  and  communi- 
cates easily  in  the  male  with  the  dartos.     All  these  parts  press  in  some 
measure  around  the  digestive,  genital  and  urinary  organs ;  the  only 
part  of  the  first  which  belongs  to  this  region  is  the  lower  part  of  the 
rectum ;  it  is  destitute  of  peritoneum  and  describes  a  curve  concave 
anteriorly ;  it  occupies  the  median  line,  and  some  anatomists  have 
wrongly  stated  that  it  deviated  a  little  to  the  right ;  .the  rectum  con- 
tracts very  much  before  terminating,  it  thus  forms  the  anus,  the  edges 
of  which  are  corrugated  and  present  longitudinal  folds,  at  the  base  of 
which  are  follicles,  which  secrete  a  very  odorous  substance.     The  rec- 
tum before  terminating  presents  an  oval  cul-de-sac,  which  is  developed 
in  a  direct  ratio  with  the  age  and  the  constipated  state  of  the  bowels  ; 
we  have  seen  it  so  much  dilated  in  old  men,  that  it  filled  the  cavity  of 
the  pelvis.     The  openings  of  the  inferior  follicles  of  this  dilatation  are 
directed  upward,  which  disposes  them  to  engorge  with  particles,  or  to 
retain  pointed  foreign  bodies  which  come  there  from  above  downward. 
The  urinary  and  genital  organs  cannot  be  mentioned  in  this  general 
description ;  it  is  sufficient  to  say  that  they  are  united,  and  that  the 
perineum  always  contains  the  bladder,  the  urethra,  and  the  erectile 
organ. 

2.  Relations.     The  skin,  the  peritoneum,  and  cellulo-fatty  layers, 
one  of  which  is  sub-cutaneous,  the  other  sub-peritoneal,  botind  this  re- 
gion, the  one  below,  the  other  above.     All  the  othe'r  organs  are  situated 
between  the  inferior  and  middle  aponeurosis,  between  this  and  the  su- 
perior.    Farther,  the  perineum  presents  two  sections,  an  anal,  and  a 
genito-urinary,  which  are  separated  by  a  line  which  would  pass  before 
the  margin  of  the  anus.     The  relations  of  the  first,  which  are  very 
similar  in  the  two  sexes,  can  alone  be  mentioned  here  ;  under  the  skin 
we  find,  in  this  point ;  first,  an  abundant  layer  of  cellular  and  adipose 
tissues,  and  on  the  sides  particularly,  a  very  large  mass  of  the  same 
nature,  situated  in  an  angle  which  is  open  downward,  and  is  formed 
by  the  union  of  the  middle  aponeurosis  with  that  of  the  obturator  in- 
ternus  muscle.     In  the  centre  of  this  angle,  and  the  tissue  which  fills 
it,  the  inferior  .hemorrhoidal  arteries  proceed,  some  lines  behind  the 
sciatic  tuberosity ;  second,  the  sphincter,  on  the  median  line,  and  oil 
the  other  points,  the  middle  aponeurosis  of  the  perineum,  which  is  here 
inferior  ;  third,  the  levator  ani  muscle  ;  fourth,  the  superior  perineal  apo- 
neurosis ;  fifth,  a  loose  cellular  layer,  and  the  peritoneum  in  every  part, 
except  posteriorly,  where  the  rectum  is  separated  from  the  coccyx  and 
from  the  sacrum  only  by  a  very  loose  cellular  tissue,  which  is  continu- 
ous with  that  of  the  meso-rectum. 
.   Sometimes  the  rectum  rests  on  all  the  points  of  this  region,  and 


208  TOPOGRAPHICAL  ANATOMY. 

extends  between  the  upper  aponeurosis  and  the  peritoneum,  which  is 
crowded  very  high  upward,  particularly  on  the  sides. 

Development.  This  region  is  formed  by  the  central  union  of  two 
parts  primitively  separated  ;  its  normal  openings  may  be  considered  as 
the  remnants  of  this  primitive  separation.  Before  the  second  month 
of  pregnancy,  the  perineum  is  cleft  in  two  parts,  and  is  similar  in  both 
sexes  which  are  not  as  yet  distinguished.  This  development  serves 
to  explain  the  abnormal  obliterations  or  unions  of  the  perineal  passa- 
ges, and  the  cases  of  hermaphrodism,  which  are  always  very  imperfect 
in  our  species. 

Uses.  The  aponeuroses  of  the  perineum  render  it  very  firm ;  the 
absence  of  the  lower  one,  however,  posteriorly,  diminishes  its  resist- 
ance in  this  part ;  its  movements  are  communicated  by  its  muscles, 
and  particularly  by  the  levator  ani,  the"  action  of  which  is  opposite  to 
that  of  the  diaphragm,  and  shortens  the  passages  which  pass  through 
this  region,  by  raising  them. 

Pathological  and  operative  deductions.  The  anal  portion  of  the 
perineum  is  sometimes  deficient,  and  not  only  the  anus,  but  the  part 
of  the  rectum  generally  found  there ;  in  this  part  it  has  been  proposed 
to  make  an  artificial  anus.  In  addition  to  our  remarks  on  this  point, 
when  speaking  of  the  iliac  and  lumbar  regions,  we  must  add,  that  an 
artificial  anus  can  be  made  through  the  perineum,  in  the  place  where 
the  anus  would  naturally  exist  in  the  normal  state ;  in  order  to  this,  it 
has  been  advised  to  introduce  a  trocar  toward  the  intestine ;  this  ope- 
ration is  often  successful,  but  may  cause  bad  symptoms,  particularly 
the  opening  of  the  peritoneum,  when  a  large  portion  of  the  rectum  is 
deficient.  We  must  not  forget  that  where  the  anus  is  deficient,  the 
intestine  sometimes  terminates  in  the  urinary  organs.  Abscesses  are 
often  situated  around  the  anus ;  the  complete  close  of  the  summit  of  the 
aponeurotic  angle  mentioned,  explains  why  they  never  fuse  from  be- 
low upward,  under  the  peritoneum,  whatever  may  be  their  size.  The 
peculiar  arrangement  of  the  follicles  above  the  anus,  explains  the  de- 
velopment of  abscesses  and  fistulse,  which  proceed  from  the  rectum 
internally.  Ribes  thinks  that  the  course  of  many  of  these  latter  is 
formed  by  one  of  the  veins  which  pass  through  the  sphincter.  He- 
morrhoidal  tumors,  as  our  dissections  have  proved,  are  all  formed  by 
varices.  Sometimes  one  vein,  and  sometimes  several  are  dilated,  and 
form  a  group  of  small  varices,  the  erectile  appearance  of  which  has 
certainly  deceived  pathologists.  The  absence  of  valves  in  these  veins,, 
(the  roots  of  the  vena  portas,)  their  passage  between  the  fibres  of  the 
sphincter,  and  the  impediment  to  the  course  of  the  blood,  produced  by 
the  contraction  of  this  muscle,  explains  the  dilatation  of  these  ves- 
sels. Sometimes  the  mucous  membrane  of  the  rectum  is  reversed ; 


PERINEUM.  209 

sometimes  small  and  elongated  ulcers  are  developed  on  the  inner  part 
of  the  sphincter,  in  the  folds  of  the  mucous  membrane ;  these  are 
fissures,  which  cause  at  first  very  severe  pains,  occasioned  by  the 
rubbing  of  the  feces  against  the  ulceration  ;  these  pains  soon  become 
constant  and  intolerable,  and  the  sphincter  muscle  being,  constantly 
excited,  finally  becomes  spasmodically  contracted,  and  thus  opposes 
the  discharge  of  feces  in  a  greater  degree.  Superficial  diseases  of 
the  perineum  cause  the  engorgement  of  the  inguinal  lymphatic  gan- 
glions, the  deep  diseases,  that  of  the  pelvic  ganglions ;  these  phenomena 
are  explained  by  the  termination  of  the  two  orders  of  the  lymphatic 
vessels.  Sometimes  hernias  exist  through  the  perineum,  depressing 
its  different  layers  of  organs ;  they  appear  most  frequently  in  the  region 
of  the  rectum,  where  the  aponeuroses  are  less  numerous  and  less  re- 
sisting. The  incisions  made  upon  the  anus  for  different  purposes  can 
never  cause  alarming  hemorrhage,  at  least  if  they  are  made  very  far 
outward,  or  from  the  side  of  the  rectum. 


1.      PERINEUM      IN      THE      MALE. 

The  perineum  in  the  male  presents  a  surface  which  can  be  measu- 
red by  drawing  two  diameters ;  first,  the  antero-posterior,  the  coccy- 
pubic,  is  four  inches ;  the  other,  the  transverse,  the  bi-sciatic,  varies, 
according  to  Dupuytren's  measurement,  between  two  and  a  half  and 
three  and  a  half  inches.  The  oblique  diameter,  which  may  be  estima- 
ted in  the  same  manner  as  the  area  of  the  lower  strait  of  the  pelvis,  is 
entirely  useless. 

The  height  of  the  perineum  in  the  male  varies  in  different  places ; 
it  is  necessary  to  know  it  exactly :  first,  between  the  inner  surface 
of  the  neck  of  the  bladder  and  the  raphe  of  the  skin,  ten  lines  before 
the  anus  ;  second,  between  the  anterior  part  of  the  margin  of  the  anus, 
and  the  base  of  the  recto-vesical  depression  of  the  peritoneum ;  in  the 
first  point,  in  ten  cadavers  which  we  have  examined,  the  height  va- 
ried between  two  inches  and  two  inches  and  eight  lines ;  in  the  second, 
between  two  inches  and  ten  lines  and  three  inches  and  six  lines.  The 
perineum  in  the  male  presents  two  faces ;  one  is  cutaneous,  the  other 
peritoneal.  The  first  presents  a  very  distinct  median  raphe,  and  con- 
tinues on  the  scrotum,  which  seems  appended  to  this  region ;  it  is  also 
covered  with  hairs,  which  are  continuous  with  those  of  the  bursse. 
The  only  opening  in  it  is  that  of  the  anus,  which  corresponds  to  the 
centre  of  a  line  drawn  between  the  summit  of  the  two  sciatic  tuberosi- 
ties :  anteriorly,  we  perceive  on  the  median  line  a  prominence,  formed 
by  the  urethra  and  its  bulb.  The  peritoneal  face  presents  only  one 

27 


210  TOPOGRAPHICAL    ANATOMY. 

depression  between  the  bladder  and  the  rectum ;  it  varies  in  depth3  and 
often  receives  folds. of  intestine. 

Structure.  —  1.  Elements.  We  find  in  man  all  those  parts  which 
have  been  mentioned  in  the  general  description,  except  his  sexual  or- 
gans; the  muscles,  however,  are  always  more  developed  in  him;  the 
ano-cavernosus  is  indivisible ;  it,  however,  is  inserted  in  a  few  points 
on  the  bulb  of  the  urethra,  which  it  coversj  and  hence  its  name  of  bul- 
bo-cavernosus.  We  find  under  the  pubio-vesical  ligament,  which 
should  here  be  termed  the  prostatic,  a  fleshy  fasciculus,  which  has  the 
same  direction  and  the  same  limits ;  it  is  the  muscle  of  Wilson. 

The  vessels  and  nerves  present  nothing  peculiar,  except  the  great 
development  of  the  superior  branches,  when  compared  to  the  inferior. 
The  perineal  apOneuroses  are  so -marked  in  the  male,  that  his  sex 
must  serve  for  a  type  of  general  description  ;  this  great  development 
forms  their  only  differential  character ;  the  inferior  aponeurosis  is 
invisible. 

The  cellular  and  adipose  tissues  present  nothing  peculiar,  except 
the  easy  continuity  of  that  which  is.  above  the  inferior  aponeurosis, 
with  that  of  the  dartos.  The  rectum  is  more  subject  in  the  male  to 
those  enlargements  which  we  have  mentioned. 

The  bladder  does  not  properly  enter  into  the  structure  of  this  region, 
but  rises  above  it;  its  neck,  however,  makes  a  part  of  it  with  the 
adjacent  regions  of  the  body,  particularly  the  trigone ;  the  neck  is  con- 
tracted, but  very  extensible  ;  the  clitoris  is  attached  to  it.  Its  entire 
circumference  is  surrounded  by  the  prostate  gland,  which  is  very  re- 
sisting, and  is  encircled  by  a  slightly  extensible  fibrous  membrane, 
which  is  very  strong,  particularly  above,  where  the  superior  perineal 
aponeurosis  is  attached  to  it.  This  sheath  of  the  prostate  gland  con- 
tains in  its  layers  a  net-work,  formed  by  the  numerous  anastomoses 
of  the  veins  of  the  prostate  gland,  of  those  of  the  neck  of  the  bladder, 
with  the  dorsal  veins  of  the  penis.  The  prostate  gland  is  situated 
beyond,  and  a  little  behind,  the  symphysis  pubis  ;  it  is  nineteen  lines 
broad,  and  thirteen  lines  high ;  the  urethra  passes  through  it,  generally 
nearer  its  upper  than  its  lower  region.  If  we  wish  to  form  an  esti- 
mate in  regard  to  the  rays  of  the  prostate  gland,  taking  the  surface 
of  the  neck  of  the  bladder  as  the  centre,  we  find  that  the  inferior  median 
ray  in  the  normal  state  measures  seven  or  eight  lines,  the  transverse 
nine  lines,  and  that  which  is  directed  obliquely  backward  and  outward 
from  ten  to  eleven  lines ;  the  superior  median  ray  measures  only  a  few 
lines. 

Besides  the  urethra,  the  prostate  gland  also  contains  within  it  the 
ejaculatory  ducts,  which  converge  towards  each  other,  and  which  be- 
come contiguous,  and  terminate  at  the  urethra,  at  the  anterior  part  of  the 


PERINEUM.  211 


verumontanum ;  finally,  we  find  in  this  region  the  'spermatic  vesicles, 
which  converge  toward  each  other  at  their  anterior  extremity,  and  are 
only  a  few  lines  distant  in  this  point ;  the  vasa  deferentia  are  situated 
near  each  other  on  the  inside,  and  flatten  and  terminate  after  becoming 


contiguous. 

o 


The  neck  of  the  bladder,  when  united  to  the  prostate  gland,  the 
ejaciilatory  duct,  &c.  is  suspended  behind  the  symphysis  by  two  very 
strong  pubio-prostatic  ligaments,  which  are  but  slightly  elastic. 

The  first  two  portions  of  the  urethra,  the  prostatic  and  the  mem- 
branous, and  even  the  bulb  and  the  origin  of  the  spongy  portion,  be- 
long to  the  perineum  of  the  male.  The  first  is  about  twelve  or  fifteen 
lines  long,  and  is  dilated  in  its  centre,  particularly  at  the  expense  of  its 
inferior  wall ;  we  find  there  the  crest  of  the  urethra,  on  the  sides 
of  which  we  see  the  adjacent  orifices  of  the  ejaculatory  ducts,  and  the 
very  broad  openings  of  the  lacunas  of  the  prostate  gland.  All  this 
portion,  and  the  half  of  the  second,  are  situated  behind  the  central 
aponeurosis,  through  which  this  passes,  six  lines  below  the  inferior 
pubic  ligament.  The  membranous  portion  is  ten  lines  long,  it  is  nar- 
row, and  its  parietes  are  thin ;  the  bulb  projects  a  little  on  its  lower 
side.  This  spungy  enlargement  is  included  in  the  opening  of  the  cen- 
tral aponeurosis,  which  terminates  on  its  sides,  and  attaches  it  firmly 
on  the  median  line;  at  the  bulb,  the  urethra  presents  a  dilatation,  the 
ventricle  of  the  bulb.  The  whole  of  the  perineal  portion  of  the  ure- 
thra thus  describes  a  curve,  concave  superiorly,: which  belongs  to  a 
circumference  of  five  inches  in  diameter.  This  curve  is  a  necessary 
effect  of  the  drawing  upward  of  the  prostate  gland,  by  the  pubio- 
prostatic  ligament,  of  the  passage  of  the  urethra  through  the  middle 
perineal  aponeurosis,  far  below  the  symphysis,  and  finally  of  the  con- 
nexion of  the  penis  before  the  pubis  by  its  suspensory  ligament ;  it 
cannot  be  effaced,  on  account  of  the  slight  elasticity  of  the  fibrous  parts 
which  cause  it..  When  the  penis  is  drawn  upward  and  laid  upon  the 
bellyr  all  the  perineal  part  of  the  urethra  is  tense ;  it  is  relaxed,  on  the 
contrary,  when  the  penis  is  depressed  and  drawn  forward.  The  con- 
sequences of  these  facts,  when  applied  directly  to  the  introduction 
of  curved  and  straight  sounds,  are  evident.  The  portions  of  the  ure- 
thra of  which  we  are  speaking,  are  filled  with  follicles,  (the  lacunas 
of  Morgagni,)  which  present  a  large  reservoir  which  looks  forward,  a 
kind  of  cavities  which  are  particularly  numerous  on  the  lower  wall. 
The  roots  of  the  cavernous  body  of  the  penis,  the  male  erectile  organ, 
are  also  situated  here. 

2.  Relations.  The  relations  of  the  rectal  portion  of  the  perineum, 
present  no  sexual  differences.  We  have  then  only  to  mention  those 
of  the  organs  included  in  the  area  of  a  triangle,  formed  by  the  rami 


212  TOPOGRAPHICAL  ANATOMY. 

of  the  arch  of  the  pubis,  and  by  a  line  drawn  between  the  summits 
of  the  two  sciatic  tuberosities  ;  it  is  the  genito-urinary  region  ;  in  pro- 
ceeding from  within  outward,  we  find  successively ;  1 .  The  hairy  skin, 
which  is  separated  into  two  parts  by  the  raphe,  in  the  course  of  which 
the  sub-cutaneous  tissue  is  very  dense,  while  it  is  loose  on  the  sides, 
and  continuous  with  the  cellular  tissue  of  the  anus,  and  that  of  the 
inner  part  of  the  thighs.  2.  The  inferior  perineal  aponeurosis,  and  in 
it,  or  directly  under  it,  the  superficial  vessels  and  nerves  of  the  peri- 
neum, situated  in  the  course  of  a  line  drawn  from  the  inner  part  of  the 
sciatic  tuberosity,  towards  the  spine  of  the  opposite  pubis.  3.  Be- 
tween this  and  the  central  aponeurosis,  first,  a  fleshy  layer,  formed  by 
the  bulbo-cavernosus,  the  ischio-cavernosi,  and  the  transversus  perinei 
muscle,  next,  the  bulb  of  the  urethra,  and  the  half  of  its  membranous 
portion  in  the  centre,  the  roots  of  the  corpus  cavernosum  on  the  out- 
side, and  between  these  parts  a  cellular  interstice,  in  which  a  few 
vessels  are  situated.  4.  The  middle  perineal  aponeurosis,  through 
which  the  urethra  passes,  and  under  it  or  in  it,  the  transverse  or  bulbar 
artery,  proceeding  transversely  fourteen  lines  in  front  of  the  anus.  5. 
Between  this  and  the  superior  aponeurosis,  the  anterior  fasciculus 
of  the  levator  arii  muscle,  a  portion  of  the  membranous  part  of  the 
urethra  embraced  by  the  preceding  muscle,  and  on  the  sides  of  which 
are  the  glands  of  Littre  and  of  Cowper,  the  prostate  gland,  the  corre- 
sponding parts  of  the  urethra,  and  the  neck  of  the  bladder.  The  mem- 
branous portion  of  the  urethra  is  separated  from  the  rectum  in  this 
point  by  a  cellular  space  of  ten  lines  only ;  the  prostatic  portion  and 
the  neck  of  the  bladder,  by  the  whole  prostate  gland,  the  corresponding 
ray  of  which  is  about  eight  lines ;  the  neck  of  the  bladder  is  covered 
above  by  some  cellular  tissue,  by  the  dorsal  veins  of  the  penis,  which 
form  there  an  important  net-work,  and  by  the  muscles  of  Wilson. 
The  bladder  and  the  rectum  are  always  separated  on  each  side  between 
the  middle  and  the  superior  aponeurosis,  by  the  seminal  vesicle  and 
the  vas  deferens,  which  is  flattened  and  placed  on  the  inside  of  the 
former.  These  two  parts  are  united  behind  the  prostate  gland,  to  the 
similar  parts  on  the  opposite  sides ;  they  diverge  very  much  superiorly 
and  anteriorly,  and  leave  between  them  a  triangular  space.  6.  The 
superior  perineal  aponeurosis,  which  is  strong  anteriorly,  but  weak 
posteriorly,  and  forms,  between  the  bladder  and  the  rectum,  a  cul-de- 
sac,  the  base  of  which,  in  the  adult,  is  three  inches  distant  from  the 
cutaneous  surface  of  this  region.  7.  A  very  loose  cellular  and  adipose 
layer.  8.  The  peritoneum,  which  often  descends  between  the  bladder 
and  the  rectum  to  the  prostate  gland,  and  is  sometimes  half  an  inch 
distant  from  this  body ;  »then,  only,  the  rectum  a'nd  the  bladder  at  its 
base  are  united  by  a  slightly  dense  cellular  tissue ;  then  only,  also, 


PERINEUM.  213 

is  there  a  recto-vesical  septum  in  a  triangular  space  formed  by  the 
diverging  of  the  seminal  vesicles  and  vasa  deferentia. 

Development.  When  developed  in  the  fetus,  the  perineum  of  the 
male  presents  no  character  to  distinguish  it  from  that  of  the  female ; 
soon  after,  however,  the  urethra  forms  from  behind  forward,  by  uniting 
in  the  centre,  so  that  its  perineal  portion  may  be  distinguished  there, 
before  that  which  belongs  to  the  penis.  This  canal  first  appears  in 
the  form  of  a  groove,  open  at  the  base,  its  upper  wall  being  formed 
first.  In  the  early  periods,  the  bladder  appears  as  a  canal,  continuous 
with  the  urethra ;  it  has  then  no  base ;  the  prostate  gland  is  slightly 
developed  and  elevated,  the  peritoneum  descends  very  low  between 
the  bladder  and  the  rectum,  even  in  very  young  fetuses ;  it  can  be  fol- 
lowed under  the  prostate  gland  and  the  membranous  portion  of  the 
urethra,  as  we  have  seen.  This  arrangement,  and  the  simultaneous 
absence  of  the  base  of  the  bladder,  continue  until  puberty,  and  often 
beyond  it ;  before  this  age,  the  perineum  in  the  male  is  destitute  of  hair. 
The  absolute  thickness  of  the  perineum  increases  with  the  age ;  its 
relative  thickness,  however,  diminishes  until  puberty,  excepting  on  the 
median  line,  where  the  peritoneum,  rising  to  form  the  recto-vesical 
septum,  increases,  on  the  contrary,  in  this  point,  in  the  same  dimension. 
In  young  subjects,  the  almost  complete  absence  of  the  anal  enlarge- 
ment of  the  rectum,  also  contributes  to  prevent  the  recto-vesical  sep- 
tum :  in  very  old  individuals,  on  the  contrary,  this  intestinal  dilatation 
often  becomes  extremely  large  ;  the  recto-vesical  septum  is  then  very 
extensive.  In  very  young  children,  the  bulb  of  the  urethra  is  small, 
and  remote  from  the  rectum  ;  it  increases  progressively  with  the  age, 
so  that  in  old  men  it  advances  toward  the  rectum,  and  extends  very 
far  laterally. 

Varieties.  The  varieties  of  the  perineum  in  the  male,  relate  to  its 
dimensions  :  we  have  already  mentioned  them :  it  is  important  to  note 
the  arrangement  of  the  prostate  gland  at  the  neck  of  the  bladder : 
sometimes  it  is  situated  entirely  upward,  and  then  the  urethra  and  the 
neck  of  the  bladder  are  very  near  the  rectum.  We  know  the  impor- 
tance of  this  abnormal  position  of  the  prostate  gland,  which  has  been 
observed  several  times  by  Senn. 

Pathological  and  operative  deductions.  The  urethra  frequently 
opens  at  the  perineum,  either  terminating  there  entirely,  or  continuing 
under  the  penis ;  this  is  perineal  hypospadias,  the  formation  of  which 
is  explained  by  the  development  of  the  region.  Abscesses  often  form 
in  its  genito-urinary  portion  :  they  may  result  from  infiltrations  of  the 
urine :  the  cellular  tissue  is  then  constantly  gangrenous :  these  effu- 
sions of  urine,  either  from  a  traumatic  rupture  of  the  urethra,  from  a 
forced  introduction  of  the  catheter,  or  from  a  violent  effort  to  expel  the 


214  TOPOGRAPHICAL  ANATOMY. 

urine,  may  occur  behind,  before,  or  at  the  bulb.  In  the  first  case, 
which  is  very  severe,  the  urine  separates  the  bladder  and  the  rectum, 
affects  the  prostate  gland  by  pointing  between  the  middle  and  supe- 
rior aponeuroses  *  in  the  second,  the  urine  goes  forward  and  upward, 
toward  the  bursae;  the  penis,  and  even  the  abdominal  wall,  following 
the  upper  face  of  the  inferior  perineal  aponeurosis,  which,  on  the  other 
hand,  opposes  its  infiltration  toward  the  anus/ although  this  part  is  the 
lowest ;  fistulas,  which  are  more  or  less  deep,  are  usually  the  result 
of  these  ruptures ;  they  likewise  cause  perineal  hypospadias.  In 
contusions  of  the  perineum,  the  urethra  may  be  crushed  and  broken; 
Without  any  affection  of  the  skin ;  we  have  seen  several  cases  of  this ; 
a  violent  hemorrhage  may  result  from  this  injury,  which  may  be 
arrested  by  introducing  a  very  large  bougie  into  the  passage.  The 
prostate  gland  is  -often  the  seat  of  tumefactions  of  various  kinds,  which 
are  perceived  through  the  rectum,  in  consequence  of  its  relations  with 
this  intestine.  It  becomes  schirrous  in  old  men,  and  then  the  neck  of 
the  bladder  is  contracted,  and  retention  of  urine  ensues.  Calculi 
sometimes  form  in  the  lacunse  of  the  prostate  gland  ;  they  are  always 
numerous,  and  of  the  mulberry  Character  ;  we  have  seen  an  individual, 
where  calculi  of  the  prostate  gland,  after  causing  inflammation  of  the 
prostate  gland,  and  its  ulceration  posteriorly,  extended  very  high  be- 
tween the  bladder  and  the  rectum,  and  were  contained  in  a  pouch  full 
of  urinous  and  purulent  liquid  ;  the  peritoneum  had  been  very  much 
crowded  upward.  Phlebolith.es  often  form  in  the  branches  of  the 
prostatic  venous  plexus.  In  this  part  of  the  perineum,  the  bladder 
may  be  punctured  in  two  ways :  first,  through  the  rectum ;  second, 
by  passing  through  the  soft  parts  of  the  perineum.  The  first  method, 
supposing  that  the  recto-vesrcal  septum  always  exists,  is  bad  on  that 
account ;  and  also  because  it  may  be  followed  by  the  injury  of  one  of 
the  vesicles,  or  of  the  vasa  deferentia,  which  are  contiguous  behind 
the  prostate  gland,  and  also  because  it  is  generally  attended  with  in- 
curable fistulae  ;  the  second*  operation  is  still  more  objectionable,  even 
with  all  its  modifications,  because  it  may  be  followed  not  only  with 
an  injury  of  the  rectum,  of  the  spermatic  vesicle, .and  even  of  the  pros- 
tate gland,  but  we  may  fail  'to  perforate  the  bladder,  or  which  is  still 
worse,  we  may  arrive  at  it  after  wounding  the  peritoneum. 

In  this  region,  also,  the  operation  of  lithotomy  is  generally  performed ; 
to  examine  it  anatomically,  we  shall  admit  only  three  methods  :  the 
median,  the  pbllque,  and  the  bilateral. 

*  It  consists  in  puncturing  the  perineum  with  a  trocar,  in  the  centre  of  a  line  drawn  between 
the  sciatic  tuberosity  and  the  raphe,  an  inch  before  the  anus  :  this  trocar  is  introduced,  at 
first,  directly  from  below  upward,  and  then  it  is  advised  to  incline  it  towards  the  median  line, 
to  avoid  the  prostate  gland. 


PERINEUM.  215 

The  median  operation  is  always  and  necessarily  attended  with  the 
injury  of  the  ejaculatory  ducts,  and  when  performed  directly  in  the 
centre,  it  is  objectionable  in  young  subjects.  If  we  wish  to  operate  with- 
out cutting  the  rectum,  the  division  of  the  neck  of  the  bladder  must  be 

D  ' 

only  seven  lines  ;  if,  on  the  contrary,  we  wish  to  cut  the  neck  of  the 
bladder  and  the  lowest  part  of  the  rectum,  we  generally  make  a  larger 
opening,  which  is  most  commonly  followed  with  incurable  fistulae.  The 
operation,  which  would  consist  in  dividing  the  prostate  gland,  the  rectum 
above  it  and  the  recto-vesicai  septum,  (an  operation  first  proposed  by 
Sanson,  but  which  we  believe  is  abandoned,)  would  be  a  rash  attempt, 
rejected  both  by  surgery  and  anatomy  ;  besides  the  objections  of  the 
median  operation,  already  mentioned,  it  is  often  attended  with  the 
opening  of  the  peritoneum,  especially  in  children,  as  happened  to 
Gery,  in  the  only  case,  happily,  where  the  bladder  has  been  so  largely 
divided.  In  performing  the  median  operation,  we  divide  successively, 
the  skin,  the  dense  cellular  tissue  of  the  raphe,  the  inferior  perineal 
aponeurosis,  the  extremities  of  the  bulbo-cavernosus  and  sphincter 
muscles,  which. are  separated  by  this  latter,  the  raphe  of  the  transversus 
perinei  muscles,  the  middle  aponeurosis,  the  inferior  part  of  the  bulb 
of  the  urethra,  its  membranous  part,  and  the  prostate  gland  below,  with 
the  neck  of  the  bladder ;  finally,  the  incision  comes  to  the  verumonta- 
num,  unless  we  follow  Dupuytren's  advice,  and  cut  a  little  on  the  side 
of  it ;  but  then  we  are  liable  to  injure  one  of  the  ejaculatory  ducts  and 
the  extremity  of  the  spermatic  vesicle  ;  finally,  on  proceeding  beyond 
the  prostate  gland,  we  also  arrive  at  that  part  of  the  rectum  which  is 
nearest  the  anus,  and  at  the  sphincter. 

In  the  lateral  operation,  we  distinguish  three  periods :  first,  the  in- 
cision of  the  soft  parts  under  the  urethra  ;  second,  the  opening  of  the 
urethra  on  the  catheter  ;  third,  the  incision  of  the  neck  of  the  bladder. 
In  the  first,  we  divide  the  skin,  the  sub-cutaneous  cellular  tissue,  the 
inferior  aponeurosis,  some  twigs  of  the  superficial  perineal  artery, 
which  is  pushed  on  the  inside  without  dividing  it,  unless  the  operation 
be  performed  too  much  on  the  side  ;  the  bulbo-cavernosus  and  trans- 
versus perinei  muscles,  the  bulb  below,  the  middle  aponeurosis,  and 
the  membranous  portion  of  the  urethra.  We  must  operate  fourteen 
lines  in  front  of  the  anus,  to  avoid  the  artery. of  the  bulb  in  the  nor- 
mal state  ;  'its  injury  at  other  times  is  inevitable  ;  the  inferior  hemor- 
rhoidal  arteries  cannot  be  wounded,  except  behind  the  sciatic  tuberosity. 
In  the  second  period,  the  urethra  alone  is  divided  ;  we  cannot  injure 
the  rectum  here,  except  by  raising  the  handle  of  the  bistoury  too  much, 
by  which  its  point  slips  from  the  groove  of  the  sound.  In  the  third 
period  we  divide,  transversely  or  obliquely,  the  neck  of  the  bladder,  the 
prostate  gland,  and  the  anterior  fasciculus  of  the  levator  ani  muscle. 


216  TOPOGRAPHICAL  ANATOMY. 

In  order  not  to  proceed  beyond  the  prostate  gland,  the  incision  should 
be  only  nine  or  ten  lines  ;  beyoncl  this,  we  wound  the  prostatic  plexus, 
and  the  urine  infiltrates  more  easily ;  we  may  injure  the  rectum,  if  it 
be  much  enlarged,  and  we  may  even  cut  the  corresponding  seminal 
vesicle :  finally,  if  the  incision  is  made  crosswise  and  broadly,  beyond 
the  prostate  gland,  we  divide  the  superior  perineal  aponeurosis,  which 
rests  on  the  sides  of  this  organ,  and  consequently  the  infiltration  under 
the  peritoneum  and  the  severest  symptoms  supervene  rapidly.  We 
must  proceed  beyond  the  bounds  prescribed  by  the  operation  to  wound 
the  trunk  of  the  perineal  artery,  which  is  situated  out  of  the  region, 
and  is  protected  by  the  bones  and  the  fibrous  parts.  In  case  this 
accident  should  happen,  the  hemorrhage  can  be  arrested  by  tying  the 
artery  on  the  inside  of  the  sciatic  tuberosity,  where  it  may  be  easily 
exposed,  and  a  ligature  can  be  applied  by  means  of  a  curved  needle, 
or  it  may  be  stopped  by  a  stitch  of  the  twisted  suture,  as  was  done  by 
Dr.  Physic,  of  Philadelphia.  Post  mortem  examination  has  generally 
shown,  that  where  severe  hemorrhage  had  led  to  the  suspicion  that 
the  internal  pudic  artery  was  wounded,  this  vessel  was  uninjured,  and 
one  of  its  branches,  generally  the  transverse,  has  been  divided.  Beclard 
has  also  made  some  experiments  upon  the  cadaver,  from  whence  it 
results,  that  it  is  almost  impossible,  in  operating  for  stone,  to  open 
the  pudic  artery,  even  when  we  attempt  it  by  making  a  large  incision. 
In  describing  the  perineum  generally,  we  have  mentioned  the  variety 
where  the  obturator  artery  sends  a  branch  towards  the  penis,  under 
the  symphysis  pubis  ;  in  this  case,  Shaw  thinks  that  the  vessel  may- 
be wounded  in  the  lateral  operation ;  this  conclusion  should  not  be 
generally  adopted. 

The  bilateral  operation,  the  advantage  of  which  is  to  obtain  a  broad 
opening  within  the  prostate  gland,  requires  the  division  of  the  skin, 
the  sub-cutaneous  cellular  tissue,  the  inferior  aponeurosis,  the  bulbo- 
cavernosus,  the  sphincter  and  transversus  perinei  muscles,  the  middle 
perineal  aponeurosis,  the  levator  ani  muscle,  the  lower  part  of  the 
bulb,  the  membranous  part  of  the  urethra,  the  neck  of  the  bladder,  and 
the  prostate  gland  transversely,  or  by  two  incisions,  which  are  more 
advantageous  according  to  Senn ;  one  oblique  on  the  left,  the  other 
transverse  on  the  right.  Farther,  we  must  also  remember,  that  the 
transverse  extent  is  nineteen  lines  only.  By  the  curved  direction  of 
the  external  incision,  we  generally  avoid  the  injuries  of  the  superficial 
perineal  arteries  and  those  of  the  bulb,  on  the  inside  of  which  the 
operation  is  performed.  The  perineal  portion  of  the  urethra  being  the 
only  part  which  presents  a  curve,  with  alternate  dilatations  and  con- 
tractions, it  is  curious  to  examine  it  for  the  introduction  of  the  catheter. 
When  the  canal  is  open,  on  account  of  its  dilatability,  catheterism  is 


PERINEUM,  217 

always  performed  easily,  whatever  may  be  the  direction  of  the  sound ; 
but  it  is  evident^  that  an  instrument  curved  like  the  urethra,  if  properly 
directed,  does  not  rub  at  its  point,  and  that  the  contrary  is  true  if  the 
instrument  is  straight,  since  it  is  impossible  for  the  passage  to  assume 
this  direction. .  Hence,  in  difficult  catheterism,  with  a  bougie  more  or 
less  pointed,  it  is  better  for  this  to  be  curved  ;  a  straight  catheter  would 
be  more  liable  to  make  a  false  passage^  especially  if  w.e  remember  that 
its  beak,  rubbing  against  the  lower  wall,  can  easily  enter  the  lacunse 
of  Morgagni,  which  are  there  very  numerous.  If  we  add  to  this, 
that  in  order  to  sound  in  this  manner,  the  penis  should  be  drawn  for- 
ward, in  which  position,  as  we  have  seen,  the  urethra  is  relaxed  to  the 
perineunij  whatever  force  may  be  exercised  on  it,  and  also  in  this 
position  some  folds  form  on  the  lower  wall  which  impede  it,  we  shall 
soon  see  that  the  rotatory  movement  which  the  use  of  these  sounds 
admits,  would  in  fact  facilitate  still  more  the  formation  of  false  passages. 
Farther,  in  order  to  introduce  the  sound,  we  must  turn  the  beak  of  the 
sound  according  to  the  curve  of  the  urethra,  on  which  its  direction 
should  be  moulded  ;  we  may  also  place  the  finger  under  the  scrotum 
or  in  the  rectum,  to  keep  the  tip  of  the  instrument  on  the  median  line. 
In  difiicult  cases,  we  must  avoid  drawing  the  penis  on  the  sound,  in 
order  to  be  able  to  seize  this  lower,  act  by  the  shorter  arm  of 'the  lever, 
and  be  more  sure  of  keeping  the  tip  of  the  instrument  in  place. 


2.    PERINEUM       IN       T  HE       FEMALE. 

The  perineum  of  the  female  presents  a  surface  which  is  extended 
in  a  measure  at  the  expense  of  its  height.  The  antero-posterior  and 
transverse  diameters,  are'  each  four  inches :  the  first  may  be  enlarged 
by  pushing  back  the  coccyx.  Anteriorly,  under  the  symphysis,  the 
perineum  in  the  female  also  presents  a  transverse  extent  of  an  inch, 
differing  thus  from  the  perineum  in  the  male,  which  terminates  there 
in  a  point. 

The  height  between  the  mucous  face  of  the  vestibule  and  the  ante- 
rior face  of  the  bladder,  was  found  to  vary,  in  twenty  subjects,  from 
ten  to  fifteen  lines;  included  between  the  meatus  urinarius  and  the 
cul-de-sac  of  the  peritoneum,  behind  the  bladder,  it  Was  from  two  to 
three  inches. 

The  perineum  in  the  female  presents  'two  faces,  one  peritoneal,  the 
other  cutaneous.  The  first  is  bounded  by  the  bladder,  the  vagina,  and 
the  rectum,  and  presents  two  depressions-;  one,  between  the  bladder 
and  the  vagina,  the  second,  between  this  latter  and  the  rectum  ;  these 
depressions  vary  in  depth.  On  the  second  face,  from  behind  forward, 

23 


218  TOPOGRAPHICAL    ANATOMY. 

I 

we  remark  the  anus,  situated  behind  the  bisciatic  line,  and  the  lower 
extremity  of  the  vagina,  which  is  expanded  to  form  the  vulva.  This 
latter  part  is  bounded  on  the  sides  by  the  external  labia,  which  are 
united  anteriorly  and  posteriorly  by  a  commissure,  the  outer  face  of 
which  is  cutaneous  and  hairy,  while  the  internal  is  mucous  and 
smooth :  on  the  inside  of  these  labia,  the  nymphse  or  internal  labia  ap- 
pear anteriorly,  united  on  the  back  of  the  erectile  organ,  the  clitoris,  a 
kind  of  penis  which  is  destitute  of  a  urethra  and  is  covered  by  a  special 
prepuce  ;  below  this  body,  between  the  internal  labia,  is  a  triangular 
surface,  bounded  posteriorly  by  the  meatus  urinarius,  this  is  the  vesti- " 
bule ;  below,  the  meatus  urinarius,  which  presents  a  very  marked  pro- 
minence, an  arrangement  which  serves  as  a  guide  in  catheterism, 
when  the  genital  organs  are  not  exposed.  The  opening  of  the  vagina 
is  situated  below  ;  in  virgins,  it  is  more  or  less  contracted,  and  closed 
in  a  certain  extent  by  the  hymen  ;  in  married  women,  however,  it 
presents,  on  the  contrary,  the  carunculae  myrtiformes. 

Structure.  —  1.  Elements.  We  find  here  all  the  elements  of  the 
general  structure  of  the  perineum,  as  has  been  mentioned,  which  ele- 
ments, however,  are  less  developed.  The  ano-cavemosus  muscle  is 
divided  into  two  parts,  and  embraces  the  lower  extremity  of  the  va- 
gina, and  hence  it  is  termed  the  sphincter  vaginae  muscle  ;  the  vessels 
and  nerves  present  only  this  peculiarity,  namely,  that  their  lower  or 
superficial  perineal  branches,  are  larger  than  the  superior.  The  infe- 
rior aponeurosis  is  divided  by  the  vagina  into  two  lateral  segments  ; 
the  central  also  presents  for  it  a  broad  opening ;  the  superior  forms  in 
this  region  two  feeble  anterior  ligaments,  which  may  be  called  the 
pubio-vesical,  the  existence  of  which  has  been  denied  by  some  authors, 
but  wrongly.  The  urethra  presents  remarkable  differences  ;  it  termi- 
nates in  the  region ;  it  is  not  surrounded  by  a  prostate  gland,  and 
does  not  turn,  like  that  in  the  male,  around  the  inferior  and  anterior 
part  of  the  symphysis  ;  it  is  directed  obliquely  downward  and  forward, 
toward  the  interval  bet\veen  the  roots  of  the  clitoris,  it  is  very  sloping 
on  the  side  of  the  bladder,  is  very  dilatable  in  all  its  parts,  and  its  mean 
length  is  one  inch.  The  bladder  corresponds  to  the  anterior  part  of 
the  perineum,  its  anterior  face  is  covered  by  the  symphysis  pubis,  which 
is  about  an  inch  high.  The  vagina  forms  the  only  true  special  organ  ;  it 
passes  through  the  perineum  in  the  female,  following  a  slight  curve  ; 
by  its  size,  it  occupies  a  considerable  space,  and  crowds  the  rectum 
and  the  anus  some  distance  backward. 

2.  Relations.  The  relations  of  the  rectal  portion  of  the  perineum 
in  the  female  need  not  be  mentioned  here  ;  they  present  nothing  spe- 
cial ;  we  shall  only  speak  of  those  of  the  genito-urinary  portion,  which 


PERINEUM.  219 

we  shall  study,  first  at  the  vestibule,  second,  on  the  side  of  the  vagina, 
third,  between  this  and  the  rectum. 

1.  Vestibule.     This  portion  is  formed,  proceeding1  from  the  outside 
to  the  inside,  by  the  following  layers ;  the  mucous  membrane,  a  semi- 
erectile  cellular  tissue,  a  very  thin  inferior  perineal  aponeurosis,  and 
under  it  the  end  of  the  superficial  vessels  and  nerves  of  the  perineum, 
the  anterior  portion  of  the  urethra,  which  is  intimately  united  to  the 
vagina,  the  anterior  extremity  of  the  sphincter  vaginas  muscle,  the 
ischio-cavernosi  muscles,  and  the  roots  of  the  clitoris,  the  middle  peri- 
neal aponeurosis  traversed  by  the  urethra,  and  containing  between  its 
layers  the  transverse  artery,  which  proceeds  from  without  inward,  at 
the  meatus  urinarius.     Between  the  middle  and  the  superior  aponeu- 
rosis we  find,  on  the  sides,  the  levator  ani  muscle,  in  the  centre,  a 
dense  cellular  layer,  which  takes  the  place  of  the  prostate  gland,  around 
which  is  a  net- work  formed  by  the  dorsal  veins  of  the  clitoris  and  those 
of  the  bladder,  the  first  passing  through  the  middle  aponeurosis  under 
the  symphysis  pubis  ;  next  comes  the  superior  perineal  aponeurosis, 
united,  by  a  loose  cellular  layer,  with  the  anterior  part  of  the  neck 
and  of  the  body  of  the  bladder  ;  at  this  part  also,  the  base  of  this  latter 
organ  blends  with  the  vagina,  and  forms  the  vesico-vaginal  septum. 

2.  Lateral  relations  of  the  vagina.     Under  the  skin  and  the  mucous 
membrane,  which  unite  and  form  the  external  labia,  while  the  internal 
are  constituted  simply  by  a  mucous  fold,  we  find ;  a  loose  cellulo-vas- 
cular  layer,  analogous  to  that  of  the  dartos,  the  inferior  perineal 
aponeurosis,  which  is  stronger  here  than  anteriorly,  under  it  the  su- 
perficial perineal  vessels  and  nerves,  the  corresponding  fasciculus  of 
the  sphincter  vaginae  muscle,  the  most  distant  part  of  the  correspond- 
ing root  of  the  corpus  cavernosum  of  the  clitoris  and  the  ischio-caver- 
nosus  muscle,  the  middle  perineal  aponeurosis,  the  leva  tor  ani  muscle, 
the  loose  sub-peritoneal  tissue,  and  the  peritoneum. 

3.  The  ano-vaginal  portion,  the  perineum  of  some  writers.     From 
the  peritoneum  to  the  skin,  the  organs  of  this  portion  of  the  perineum 
are  situated  in  a  triangular  space,  the  base  of  which  is  at  the  skin, 
while  one  of  the  edges  is  formed  by  the  vagina,  the  other  by  the  rec- 
tum, and  the  summit  which  looks  upward,  results  from  the  union  of 
these  two  organs,  and  forms  the  recto-vaginal  septum ;  the  organs 
there  present  themselves  from  without  inward  in  the  following  rela- 
tions ;  the  skin,  the  anterior  extremity  of  the  sphincter  ani  attached 
below  the  inferior  aponeurosis  of  the  perineum,  this  aponeurosis  itself, 
the  posterior  extremity  of  the  sphincter  vaginae  inserted  above  this  lat- 
ter, the  transversus  perinei  muscle,  the  middle  perinea]  aponeurosis,  a 
dense  cellular  tissue  which  unites  the  rectum  and  vagina,  and  finally, 
the  posterior  depression  of  the  peritoneum. 


**>  TOPOGRAPHICAL  ANATOMY. 

Development.  In  the  early  development,  the  perineum  of  the  fe- 
male is  remarkable  for  the  size  of  the  clitoris,  which  assimilates  this 
region  to  that  of  the  male,  considered  when  the  urethra  is  not  formed 
under  the  erectile  organ.  Farther,  the  nymphas  are  very  long  and 
extended  under  the  clitoris,  and  then  resemble  the  urethra  of  the  male. 
Until  puberty,  the  perineum  of  the  female  is  contracted  transversely, 
and  its  height  seems  to  increase  there  ;  the  peritoneal  depressions  are 
deeper  ;  after  this  age  it  assumes  the  characters  indicated  as  types.. 

Varieties.  The  deviations  in  the  formation  of  the  outlet  of  the  pel- 
vis also  cause  in  the  perineum  of  the  female  frequent  individual 
varieties. 

Pathological  and  operative  deductions.  The  manner  in  which  the 
perineum  is  developed  explains  admirably  the  absence  of  the  vagina, 
its  obliteration  by  a  simple  membrane,  the  obliteration  of  the  urethra, 
or  the  abnormal  union  of  the  digestive  and  genito-urinary  organs  in 
one  cavity,  a  kind  of  cloaca  similar  to  that  of  birds,  reptiles,  and  fishes  ; 
finally,  the  enormous  development  of  the  clitoris  in  female  hermaphro- 
dites, which  resembles  the  penis.  The  direct  relations  of  the  bladder 
and  of  the  rectum  with  the  vagina,  account  for  those  disgusting  com- 
munications between  the  canals  of  the  perineum,  caused  by  ulcera- 
tions  of  different  characters.  Perineal  hernias  occur  more  frequently 
here  on  account  of  the  thinness  of  the  region,  and  particularly  on 
account  of  the  debility  which  results  from  repeated  pregnancies.  The 
relaxed  parietes  of  the  vagina  sometimes  yield  and  form  pouches,  into 
which  the  abdominal  organs  descend,  (vaginal  hernias.)  Diseases  of 
the  anus  are  less  frequent  in  the  female  than'  in 'the  male,  because  the 
parts  are  less  developed.  The  sub-pubic  operation  of  lithotomy  is  per- 
formed by  dividing  the  anterior  portion  of  the  perineum  in  the  female, 
the  vestibule.  .The.  incisions  made  for  this  purpose -may  be  referred, 
as  in  the  male,  to  three  directions  ;  the  median,  .the  lateral,  and  finally 
the  bilateral. 

The  first  mode  of  incision  comprises  the  method  of  Dubois  and  the 
vesico-vagina'l  method ;  sometimes  in  this  latter,  the  vesico-vaginal 
septum  alone  is  divided,  as  seems  to  have  been  done  by  Rousset  and 
Fabricius ;  sometimes,  on  the  contrary,  according  to  the  advice  of  Yacca, 
we  divide  the  urethra,  the  neck  of  the  bladder,  and  the  corresponding 
part  of  the  vagina ;  in  Dubois'  method  we  divide  successively ;  the 
mucous  membrane,  the  inferior  aponeurosis,  some  small  vessels,  the 
middle  aponeurosis,  the  superior  wall  of  the  urethra,  the  neck  of  the 
bladder  with  the  vascular  net-work  which  surrounds  it,  and  the  supe- 
rior perineal  aponeurosis.  The  shortness  of  the  canal  of  the  wound, 
and  particularly  the  facility  with  which  the  urine  escapes,  indicate 
sufficiently  the  safety  of  this  method,  in  which  we  should  not 


CIRCUMFERENCE  OF  THE  PELVIS.  221 

approach  too  near  to  the  symphysis,  in  order  to  avoid  the  clitoris  and 
its  vessels.  In  the  operation  through  the  vagina,  we  are  exposed,  when 
we  wish  to  divide  the  vesico-vaginal  septum,  to  cut  the  peritoneum, 
and  in  all  cases  to  leave  vaginal  fistulas. 

The  second  mode  of  incision  of  the  neck  of  the  bladder  and  of  the 
vestibule,  constitutes  the  lateral  operation  in  the  female,  a  method  in 
which  we  cut  the  mucous  membrane,  the  inferior  aponeurosis,  the 
anterior  extremity  of  the  bulbo-cavernosus,  the  transversus  perinei,  the 
middle  aponeurosis,  the  anterior  part  of  the  levator,  the  urethra  ob- 
liquely backward,  the  neck  of  the  bladder,  and  its  venous  net-work. 
We  must  proceed  beyond  the  vestibule  to  open  the  transverse  artery  ; 
the  superficial  is  situated  too  far  on  the  outside  to  be  wounded.- 

The  third  mode  of  incision  comprises  the  double  division  of  the 
neck  of  the  bladder  and  of  the  urethra,  as  has  been  proposed  by  Louis 
and  performed  by  Flurant,  who  has  invented  for  this  purpose  a  double 
lithotome.  The  vestibule  is  also  divided  bilaterally,  in  the  method 
mentioned  by  Celsus,  and  also  in  that  of  Lisfranc,  which  consists  in 
arriving  on  the  anterior  wall  of  the  bladder,  by  dividing  the  vestibule 
in  such  a  manner,  that  the  curve  embraces  the  urethra,  but  does  not 
touch  it ;  the  other  parts  which  are  divided  in  this  operation  are  the 
same  as  in  the  lateral  operation.  Lisfranc  thinks  that  we  can  thus 
prevent  in  females  that  incontinence  of  urine,  which  is  so  common 
after  the  other  modes  of  operating. 


ORDER-    SECOND. 

.    CIRCUMFERENCE    OF    THE    PELVIS. 

The  circumference  of  the  cavity  of  the  pelvis  forms,  at  the  lower 
part  of  the  abdomen,  a  resisting  surface,  on  the  outside  of  which  the 
lower  extremities  are  supported,  and  which  sustains  posteriorly  the 
weight  of  the  body.  This  great  region,  the  limits  of  which  are  well 
marked  upward  and  downward,  has,  for  its  skeleton,  the  sacrum  and 
the  coccyx  posteriorly,  the  iliac  bones  on  the  sides  and  anteriorly.  It 
is  also  formed  by  some  fibrous  parts,  the  .obturator  membrane  imper- 
fect above,  the  sacro-sciatic  ligaments,  not  to  mention  the  ligaments  of 
the  symphysis  pubis.  The  soft  parts  are  situated  inside  and  outside  of 
the  skeleton,  forming,  in  fact,  two  planes  or  secondary  regions,  the 
intra-pelvic,  and  the  extra-pelvic. 

The  circumference  of  the  pelvis,  considered  generally,  participates 
in  the  development  of  the  perineum  and  of  the  abdomen,  by  two 
lateral  pieces,  which  serves  perfectly  to  explain  its  principal  deviations, 
such  as  its  division  anteriorly,  in  extrophy  of  the  bladder,  and  poste- 


222  TOPOGRAPHICAL   ANATOMY. 

riorly,  in  spina  bifida.  f  In  the  male,  the  height  of  this  part  of  the  ab- 
dominal parietes  is  developed  particularly  ;  its  breadth  predominates 
in  the  female. 


1.       INTRA-PELVIC       PORTION. 

This  part  of  the  circumference  of  the  pelvis  forms  a  single  region, 
called  the  intra-pelvic.  It  terminates  at  the  margin  of  the  pelvis,  and 
presents  a  peritoneal  face,  undivided  in  the  male,  separated  in  the  fe- 
male into  two  parts,  an  anterior  and  a  posterior,  by  the  broad  ligaments 
of  the  uterus. 

Structure. — 1.  Elements.  Many  parts  which  we  have  studied  in 
the  perineum  extend  here  by  curving  upward  ;  these  are  the  perito- 
neum, the  superior  perineal  aponeurosis,  which  deserves  in  this  point 
the  term  fascia  pelvia,  given  by  some  authors,  particularly  Cloquet,  the 
levator  ani  muscle  and  its  inferior  aponeurosis  posteriorly ;  we  also 
find  in  this  region  the  obturator  internus,  pyramidalis,  and  ischio- 
coccygoBUS  muscles,  an  aponeurosis  which  forms  the  sheath  of  the 
obturator  internus  muscle.  This  latter  is  situated  on  the  limits  of  the 
perineum,  arises  from  the  external  face  of  the  middle  perineal  aponeu- 
rosis, descends  perpendicularly  on  the  inner  face  of  the  obturator 
internus,  and  terminates  on  the  falciform  edge  of  the  great  sacro-sciatic 
ligament ;  it  is  very  strong  inferiorly,  where  it  encloses  between  two 
layers,  the  trunks  of  the  pudic  vessels  and  nerves  posteriorly,  and  their 
superior  branches  anteriorly ;  it  constitutes  the  outside  of  a  fibrous 
cavity,  filled  with  cellular  tissue  in  the  anal  region.  The  hypogastric 
artery  and  all  its  branches,  at  their  origin,  belong  to  this  region,  with 
their  attendant  veins,  and  also  many  lymphatic  ganglions,  which  are 
termed  the  pelvic  ganglions,  which  receive,  not  only  the  lymphatic 
vessels  of  the  region,  but  also  those  of  the  deep  part  of  the  perineum, 
of  the  buttock,  of  the  posterior  part  of  the  thigh  and  of  the  pelvis.  On 
issuing  from  the  sacral  foramina,  the  anterior  branches  of  the  sacral 
nerves  are  situated  in  the  pelvis,  send  to  it  some  twigs,  and  form  by 
their  angular  union  the  sacral  plexus,  which  is  united  to  the  lumbar 
plexus  by  the  lumbo-sacral  nerve  ;  we  also  find  there  the  last  portion 
of  the  tri-splanchnic  nerve  and  their  ganglion  of  union,  the  coccygo3al, 
some  very  loose  cellular  and  adipose  tissue,  and  separated  by  some 
aponeuroses  from  those  of  the  perineum,  but  communicating  with 
those  of  the  thigh  and  the  buttock,  through  the  sub-pubic  and  ischiatic 
openings. 

2.  Relations.     The  arrangement  of  these  parts,  from  the  peritoneum 
toward  the  bones,  is  as  follows :  anteriorly,  on  the  median  line,  the 


INTRA-PELVIC  PORTION.  223 

body  of  the  bladder,  in  relation  by  its  anterior  face,  and  united  with 
the  bodies  of  the  pubis,  and  with  their  prominent  symphysis,  on  this 
side^  by  a  loose  cellular  layer  ;  always  anteriorly,  but  on  the  right  and 
left  of  the  median  line,  we  find  the  peritoneum,  a  lamellar  cellular 
layer,  the  pelvic  aponeurosis,  and  the  obturator  internus  muscle, 
above  ;  below,  on  the  contrary,  the  peritoneum,  the  pelvic  aponeurosis, 
the  levator  ani  muscle,  the  angle  of  separation  of  the  middle  aponeu- 
rosis of  the  perineum,  and  of  that  of  the  obturator  muscle,  this  last 
including  between  its  layers  the  pudic  vessels  and  nerves,  which  rest 
against  the  bones ;  finally,  the  obturator  muscle,  which  is  very  thick 
in  this  point.  At  this  height  is  situated  the  sub-pubic  ring,  formed 
above  by  the  horizontal  ramus  of  the  pubis,  below  by  the  pelvic  apo- 
neurosis, an  opening  which  encloses  the  obturator  vessels  and  nerves, 
which  rest  against  its  outer  side.  On  the  sides  of  this  intra-pelvic 
region,  and  superiorly,  we  find  the  peritoneum,  a  loose  cellular  layer, 
in  which  the  obturator  vessels  and  nerves  glide  from  behind  forward, 
the  pelvic  aponeurosis,  the  obturator  internus  muscle,  and  also  the 
sciatic  foramen,  formed  by  the  pelvic  aponeurosis  below,  and  the  great 
sciatic  notch  above,  through  which  ring  pass  the  gluteal  vessels  ;  be- 
low, we  find  the  levator  ani  muscle,  its  inferior  aponeurosis,  the  fibrous 
angle  of  the  anal  portion  of  the  perineum,  the  aponeurosis  of  the  ob- 
turator muscle,  with  the  pudic  vessels  and  nerves,  and  the  obturator 
muscle.  Finally,  at  the  posterior  part  of  the  intra-pelvic  region,  under 
the  peritoneum,  which  is  deficient  at  the  rectum,  are  a  cellular  and 
an  adipose  layer,  which  contain  the  hemorrhoidal,  vaginal,  and  vesical 
vessels  ;  the  venous,  lymphatic,  and  nervous  hypogastric  plexuses ;  the 
pelvic  artery  and  vein,  situated  on  the  side  before  the  sacro-iliac  sym- 
physis ;  the  pelvic  aponeurosis,  blended  with  the  periosteum  of  the 
sacrum  ;  the  great  sympathetic  nerve  and  the  sacral  plexus,  the  pyra- 
midalis  and  ischio-coccygoeus  muscles,  surrounded  by  a  loose  cellular 
tissue. 

Varieties.  The  obturator  artery  sometimes  comes  from  a  trunk  in 
common  with  the  epigastric  artery,  or  from  the  external  iliac  artery : 
it  is  then  situated  in  front  of  the  region,  behind  the  ramus  of  the  pubis, 
at  the  upper  part  of  the  sub-pubic  ring.  This  artery  sometimes  sends 
off  obliquely,  under  the  symphysis,  a  considerable  branch. 

Pathological  and  operative  deductions.  The  lymphatic  ganglions 
of  the  pelvis  engorge  in  diseases  of  the  pelvic  organs,  and  also  in  those 
situated  deeply  in  the  perineum,  in  the  buttock,  and  in  the  posterior 
part  of  the  thigh ;  some  purulent  and  sanguineous  collections  pass 
into  it  from  below  upward,  through  the  sub-pubic  and  sciatic  foramina, 
in  the  purulent  or  sanguineous  sub-aponeurotic  effusions  of  the  pelvic 
extremity.  We  have  verified  these  assertions  in  two  individuals,  at 


224  TOPOGRAPHICAL   ANATOMY. 

the  Hospital  La  Charite,  in  whom  the  thigh  was  amputated ;  in  one, 
the  blood  had  penetrated  into  the  pelvis,  through  the  great  sciatic 
fissure ;  in  the  other,  pus  had  arrived  there  through  the  same  point, 
and  through  the  sub-pubic  ring.  Congested  abscesses  of  the  sacrum 
anteriorly,  and  even  those  of  the  loins, ;  have  sometimes  pointed 
at  the  thigh,  through  the  sub-pubic  ring;  from  this  point,  the  pains  of 
sciatic  neuralgia  extend.  Hernias  may  occur  through  the  sub-pubic 
and  sciatic  rings  ;  they  may  even  be  strangulated  there  :  the  position 
of  the  sub-pubic  vessels,  on  the  outside  of  the  sub-pubic  ring,  that -on 
the  inside  and  above,  assumed  by  these  vessels  when  they  come  from 
a  trunk  in  common  with  the  epigastric'  artery,  shows  that  the  inner 
and  inferior  part  is  that  on  which  we  must  operate.  On  the  upper 
boundary  of  this  region,  Dr.  Stevens  has  tied^the  hypogastric  artery, 
in  a  case  of  gluteal  aneurism. 


2.       E  X  T  R  A-P  ELVIC       PORTION. 

This  part  of  the  circumference  of -the  pelvis  blends  on  the  sides  with 
the  pelvic  limbs,  of  which  it  forms  the  first  section  ;  we  shall  mention 
it  in  another  place  ;  posteriorly  and  anteriorly  it  is  loose,  and  constitutes 
the  posterior  sacral  and  pubic  regions,  at  the  same  time  that  it  supports 
in  the  male  the.  external  genital  organs  and  the  regions  which  they 
form* 


1.   POSTERIdR   SACRAL   REGION. 

The  posterior  sacral  region  is  continuous  above  with  the  lumbar 
portion  of  the  spinal  face  of  the  trunk  ;  below,  it  extends  to  the  peri- 
neum ;  laterally,  it  is  bounded  by  the  posterior  prominence  of  the  ilium. 
Its  outer  face  is  depressed  in  the  centre,  and  presents  the  raphe  :  the 
bones  there  are  easily  felt,  particularly  below. 

Structure* — 1.  Elements.  The  elements  of  this  part  are  few  in 
number;  they  rest,  on  the  sacrum,  the  coccyx,  and  the  iliac  bones, 
which  unite  and  form  two  grooves,  separated  by  the  median  crest : 
among  the  numerous  ligaments  which  unite  them,  it  is  important  to 
remember  the  posterior  sacro-coccygosal  ligament, .  which  closes  the 
terminating  groove  at  the  bottom  of  the  sacral  canal,  and  under  which 
the  arachnoid  membrane  of  the  spinal  marrow,  and  the  cavity  which 
it  forms,  extend.  The  mass  of  the  sacro-lumbalis  and  longissimus 
dorsi,  and  the  semi-spinalis  dorsi  muscles,  begin  in  this  point,  where 
we  also  find  the  inferior  aponeurosis  of  the  latissimus  dorsi  muscle, 


POSTERIOR  SACRAL  REGION.  225 

and  some  fibres  of  the  glutgeus  maximus  muscle.  The  skin  presents 
nothing  peculiar  ;  the  arteries  leave  the  sacral  canal,  they  come  from 
the  lateral  sacral  arteries,  and  anastomose  with  the  lumbar :  the  veins 
go  into  the  vertebral  sinuses ;  the  superficial  lymphatic  vessels  belong 
to  the  inguinal  ganglions  ;  the  deep,  to  the  pelvic  ganglions :  the 
nerves  come  through  the  posterior  sacral  foramina,  and  are  the  poste- 
rior branches  of  the  sacral  nerves  ;  the  cellular  tissue  is  loose,  and  in 
small  quantity  under  the  muscles  ;  it  is  more  dense  on  the  outside, 
particularly  on  the  median  line ;  the  sacral  canal  corresponds  to  this 
region,  and  the  principal  nerves  of  the  lower  extremity  come  from  it 
through  the  anterior  arid  posterior  sacral  foramina,  which  are  situated 
on  the  same  level. 

2.  Relations.  The  skin  in  the  centre  is  doubled  by  a  dense  cellular 
tissue,  which  attaches  it  intimately  to  the  crest  of  the  sacrum  and  to 
the  coccyx ;  more  deeply,  we  find,  successively,  the  aponeurosis  of 
the  latissimus  dorsi,  from  which  arise  some  fibres  of  the  glutseus  maxi- 
mus, the  very  strong  aponeurosis  of  the  sacro-spinalis,  the  fleshy  por- 
tion of  this  latter  muscle  and  the  sacrum ;  the  skin  and  the  coccyx 
are  separated  only  by  some  cellular  tissue  and  by  some  fibrous"  pro- 
ductions. The  arteries  proceed  from  before  backward  to  the  skin ; 
they  are  but  of  little  importance. 

Pathological  and  operative  deductions.  From  our  statements,  it 
follows,  that  in  falling  on  the  buttock,  the  coccyx  may  be  easily  frac- 
tured, if  it  be  fused  with  the  sacrum  ;  this  latter,  also,  must  be  very 
much  jarred,  as  likewise  the  nerves  which  it  protects,  which  may  give 
rise  to  a  more  or  less  perfect  paralysis  of  the  extremities,  the  bladder, 
and  the  rectum.  The  sacrum  is  rarely  fractured  in  these  falls,  as  the 
iliac  bones  in  fact  support  the  shock,  because  they  project  much  more 
posteriorly.  A  wounding  instrument,  directed  from  below  up  ward,  might 
enter  at  the  lower  part  into  the  sacral  canal,  which  is  protected  in  this 
point  only  by  the  skin  and  the  posterior  sacro-coccygosal  ligament ;  the 
breadth  of  the  posterior  sacral  foramina  above,  their  correspondence 
with  the  anterior,  shows  the  possibility  of  injuring  the  organs  in  the 
cavity  of  the  pelvis,  by  a  stylet  carried  from  behind  forward  in  this 
region,  xvithout  producing  a  fracture  of  the  sacrum.  Beclard  men- 
tioned a  remarkable  instance  of  this  in  his  course,  where  the  bladder 
was  affected  in  this  manner.  Enormous  eschars  often  appear  here,  in 
diseases  of  long  standing ;  when  they  slough  off,  the  sacrum  and  the 
coccyx  may  be  denuded  and  affected.  In  these  cases,  we  have  twice 
seen  the  cavity  of  the  arachnoid  membrane  opened  :  this  fact  is  very 
important,  as  it  accounts,  to  a  certain  extent,  for  the  severe  and  rapidly 
fatal  symptoms  which  mark  the  last  period  of  many  adynamic  fevers, 
complicated  with  eschars  in  this  region. 

29 


225  TOPOGRAPHICAL  ANATOMY. 


2.       PUBIC       REGION. 

The  pubic  region  is  very  simple  ;  it  is  convex  anteriorly,  particularly 
in  the  female,  and  at  puberty  is  covered  with  hair  ;  it  is  bounded  on 
the  outside  by  the  spines  of  the  pubis,  above  and  below  by  the  upper 
and  lower  edges  of  the  symphysis. 

Structure. — 1.  Elements.  The  body  of  the  pubis  serves  as  a  point 
of  support  to  this  region ;  it  forms  there  the  symphysis  pubis,  before 
which  many  fibrous  parts,  terminate.  The  first  adductor  muscles  and 
the  rectus  internus,  commence  here,  and  also  the  rectus  abdominis  and 
pyramidalis  ;  but  all  of  these  belong  but  slightly  to  the  region  of  which 
we  are  speaking ;  in  the  female,  the  round  ligament  passes  through  it, 
and  terminates  here  ;  in  the  male,  the  spermatic  cord  merely  passes 
through  it.  Its  arteries  come  from  the  external  pudic  arteries ;  the 
veins  correspond  to  them  very  exactly;  the  lymphatics  go  to  the  in- 
giiinal  ganglions  ;  the  nerves  come  from  the  lumbar  plexus,  and  par- 
ticularly from  the  ilio-scrotal  or  vulvar  and  the  genito-crural  branches. 
The  cellular  and  adipose  tissues  are  very  abundant  here. 

2.  Relations,  The  skin,  the  cellulo-fatty  layer  in  which  the  vessels 
and  nerves  are  situated,  the  spermatic  or  sub-pubic  cords  on  the  outside, 
the  pubes  and  their  symphyses,  are  the  layers  of  this  portion  of  the 
pelvis. 

Development.  In  very  young  female  fetuses,  we  find  in  this  region, 
along  the  round  ligament,  a  prolongation  of  the  peritoneum,  which  is 
afterwards  obliterated,  the  canal  of  Nuck.  In  male  fetuses,  until  birth, 
we  find  on  the  spermatic  .cord,  the  unobliterated  neck  of  the  vaginal 
tunic. 

Pathological  and  operative  deductions.  In  this  place,  we  make 
the  incision  in  symphysiotomy  according  to  Sigault's  method,  in  order 
to  obtain  a  slight  separation  of  the  bones,  and  thus  produce  artificially 
in  the  female  what  occurs  naturally  in  certain  animals,*  from  tire  great 
extension  of  the  fibrous  substances  of  the  •symphysis.  .  Encysted  tumors 
often  appear  in  this  region,  and  particularly  in  females  ;  in  them  they 
are  sometimes  the  remnants  of  the  canal  of  Nuck. 

*  In  the  family  of  the  rodentia,  arid  particularly  in  the  capybara. 


SCROTAL  REGION.  227 


3.       EXTERNAL      -GENITAL      ORGANS. 

The  external  genital  organs  are  attached  to  the  pubic  region  of  the 
perineum,  and  also  to  the  anterior  wall  of  the  abdomen ;  the  regions 
which  they  form,  although  peculiar  to  the  male,  have  their  analogies 
in  the  female,  although  in  her  they  are  in  a  measure  rudimentary, 
and  are  confined  to  the  perineum,  where  we  have  considered  them. 
These  regions  are  those  of  the  testicles  and  of  the  penis. 


1.   TESTICULAR   OR   SCROTAL   REGION. 

This  region  is  continuous  posteriorly  with  the  perineum,  but  the 
separation  is  not  very  distinct,  and  anteriorly  with  the  pubic  region  ; 
it  is  separated  from  the  thigh  by  a  groove,  in  which  numerous  cuta- 
neous follicles  are  situated.  .. 

Its  surface  is  more  or  less  extensive,  the  median  -raphe  is  there  very 
distinct,  and  divides  it  into  two  .lateral.'  portions,  of  which  the  left  al- 
ways descends  lower  than  the  right  ;*  in  young  and  strong  subjects, 
we  perceive  some  very  distinct  transverse  wrinkles,  some  hairs  which 
are  continuous  with  those  of  the  pubis  and  perineum ;  these  are  the 
other  external  characters  of  this  part  of  the  body. 

On  the  right  and  left  of  the  raphe  is  a  serous  cavity;  it  is  entirely 
distinct  in  the  normal  state,  and  contains  only  a  thin  serous-  vapor ; 
the  testicle  and  epidydimis  cause  it  to  project  posteriorly: 

Structure.  —  1.  Elements.  This  region  presents- no  osseous  part, 
resembling  in  this  respect  the  abdominal  region,  of  which  it  is  evidently 
a  prolongation,  and  of  which  it  has  the  structure.  We  find,  also,  the 
skin  which  constitutes  the  scrotum,  the  dartos,  a  cellular-  fibrous  layer, 
which  is  continuous  with  the  fascia  superficialis,  is  attached  to  the 
branch  of  the  ischium,  and  resting  on  the  median  line,  against  that 
of  the  opposite  side,  .forms  a  .true  septum,  a  fibrons  expansion  which 
is  detached  from  the  edge  of  the.  inguinal  ring,  and  which  cannot  be 
traced  beyond  the  cord,  the  cremaster  muscle,  composed  of  fibres'of  the 
.  obliqmis  internus  and  transversalis  muscles,  and  which  presents  two 
fasciculi,  an  external)  which  is  the  larger,  and  an  internal.  The  cre- 
master exists  only  before  the  cord;  although  some,  of  .its  fibres  may 

*  This  difference  has  been  attributed  to  the  left  lateral  curve  of  the  trunk  and  of  the  dorsal 
region  •  we- think  that  it  depends  much  more  on  the  habitually  greater  dilatation  of  the  tcs- 
ticular  veins  on  this  side  ;  this  dilatation  is  produced,  by  the  pressure  of  thesigmoid  flexure 
of  the  colon,  which  causes  the  weight  of  a  greater  column  of  blood  on  the  left  testicle,  and 
this  is  consequently  depressed. 


TOPOGRAPHICAL    ANATOMY. 

also  be  found  behind  it ;  farther,  the  fibres  of  the  cremaster  muscle,  as 
Cloquet  has  demonstrated,  describe  plexuses,  concave  superiorly ;  we 
find  also  in  this  region,  the  fibrous  sheath  common  to  the  testicle  and 
the  cord,  a  kind  of  pyriforrn  sack,  continuous  in  the  inguinal  canal 
with  the  infundibulum  of  the  fascia  transversalis,  and  finally  the  va- 
ginal tunic,  which  forms  the  parietes  of  the  serous  cavity,  envelopes 
the  testicle  only  anteriorly,  extending  a  little  before  the  cord,  and  uni- 
ting above  tQ  the  peritoneum,  which  passes  on  the  upper  orifice  of  the 
inguinal  canal,  by  a  cellular  cord,  the  remnant  of  the  obliterated  neck 
of  the  vaginal  tunic.      These  different  layers  receive  some  arteries 
from  the  crural  artery,  (the  external  genital)  and  from  the  superficial 
perineal  artery,  which  forms  the  artery  of  the  septum ;  their  veins  are 
very  broad  and  numerous,  and  accompany  the  arteries ;  their  lympha- 
tics go  to  the  superficial  inguinal  ganglions.     The  nerves  come  from 
the  lumbar  plexus,  and  particularly  from  the  ilio-scrotal  and  genito- 
crural  branches ;  the  small  sciatic  nerve  from  the  sacral  plexus  termi- 
nates there  also ;  the  cellular  tissue  is  very  loose,  and  contains  no 
adipose  vesicles  inferiorly ;  some  are  found  superiorly ;  finally,  the 
testicle  and  its  cord  occupy  the  centre  of  this  region.     The  description 
of  these  latter  organs  belongs  to  descriptive  anatomy ;  we  will  only 
mention,  that  the  spermatic  cord  is  formed  by  the  peritoneo-vaginal 
cellular  ligament,  which  has  been   mentioned,  by  the  arteries  and 
nerves  which  go  to  the  testicle,  and  by  the  excretory  ducts  and  veins 
which  leave  it ;  all  these  parts  are  united  by  a  loose  cellular  tissue,  in 
the  centre  of  which,  adipose  masses  are  sometimes  developed  superi- 
orly.    The  artery  of  the  testicle  comes  from  the  aorta  at  a  very  acute 
angle,  and  sometimes  from  the  renal  artery ;  it  is  covered  by  the  plexus 
of  the  testicular  nerves  given  off  by  the  great  sympathetic  nerve ;  the 
veins  of  the  testicle  are  at  first  numerous,  and  then  unite  in  one  trunk ; 
after  this,  they  separate  and  anastomose  to  form  the  pampiniform 
body,  and  again  unite  to  go  to  the  vena  cava,  or  the  renal  vein,  par- 
ticularly on  the  left ;  these  veins  inferiorly  have  no  valves ;  they  are 
very  broad,  on  the  left  particularly,  where  they  pass  into  the  belly,  be- 
hind the  sigmoid  flexure  of  the  colon ;  the  lymphatics  of  the  testicle 
go  to  the  lumbar  ganglions. 

2.  Relations.  The  relations  of  this  region  are  extremely  simple ; 
they  must  be  studied  around  the  testicle  and  its  cord,  considered  as  a 
centre.  The  skin  forms  the  first  layer ;  then  come  successively ;  the 
semi-contractile  tissue  of  the  dartos,  in  which  are  situated  the  external 
genital  vessels  and  the  superficial  perineal  artery,  an  expansion  detach- 
ed from  the  inguinal  ring,  the  cremaster  muscle,  which  is  generally 
deficient  posteriorly,  the  sheath  common  to  the  cord  and  the  testicle, 


SCROTAL  REGION.  229 

the  vaginal  tunic  situated  below,  before  the  testicle  and  the  adjacent 
part  of  the  cord,  and  finally  these  two  parts. 

Development.  At  first  this  re'gion  'is  entirely  deficient ;  but  it  soon 
appears  on  each  side  of  a  deep  groove  which  exists  in  the  perineum  in 
the  early  periods.  It  is  not  well  developed  until  the  testicles  have 
come  into  it ;  before  this  period  there  is  no  creniaster  muscle ;  this 
muscle  forms  when  the  testicle  passes  under  the  obliquus  interims  and 
transversalis,  the  lower  fibres  of  which  it  draws  down ;  then,  also,  are 
formed,  the  vaginal  tunic,  the  dartos,  and  the  common  sheath  of  the 
cord  and  testicle,  by  the  depression  of  the  peritoneum,  and  of  the  fascia 
superficialis  and  transversalis.  At  first,  the  vaginal  tunic  communi- 
cates with  the  peritoneum,  by  a  passage  which  forms  its  neck  ;  this  is 
contracted  shortly  after  birth,  and  thus  changes  into  a  cellular  cord ; 
sometimes  this  is  obliterated  only  in  certain  points,  and  it  remains 
open  in  others. 

Varieties.  In  some  individuals  the  testicles  do  not  descend,  and 
the  changes  we  have  mentioned  do  not  occur,  until  very  late ;  in  oth- 
ers, the  communication  of  the  vaginal  tunic  with  the  peritoneum  re- 
mains for  a  long  time,  and  even  during  existence.  It  has  been  stated 
that  one  testicle,  or  both,  are  sometimes  deficient.  In  these  cases, 
the  testicles  have  most  generally  remained  abnormally  in  the  abdomen. 
In  one  case,  however,  we  have  found  but  one  testicle  in  this  region, 
and  after  examining  carefully,  we  could  find  none  in  the  abdomen, 
nor  was  there  any  trace  of  the  cord,  the  vas  deferens,  or  of  the  cor- 
responding vesicle  on  this  side  ;  there  was  no  incision  on  the  scrotum. 

Pathological  and  operative  deductions.  This  region  is  cleft  in 
some  monstrous  fetuses ;  a  vestige  of  the  primitive  development  has 
often  led  to  errors  in  regard  to  the  sex,  particularly  if  the  testicles  con- 
tinue in  the  abdomen.  Wounds  in  this  region  are  remarkable  for  their 
progress ;  there  is  always  an  excess  of  skin ;  the  latter,  on  account  of 
its  flaccidity,  always  turns  inward ;  its  bloody  edge  comes  in  contact 
with  the  base  of  the  wound,  and  not  with  the  edge  of  the  opposite  lip ; 
hence  a  cicatrix  which  is  always  slow  in  forming,  and  is  always  de- 
pressed in  a  groove.  In  this  region  inguinal  hernias  are  situated  ;  in 
the  female,  they  descend  into  the  external  labium ;  the  different  layers 
which  we  have  mentioned,  develop  themselves  in  proportion  to  the 
duration  of  these  diseases,  and  hence  they  sometimes  cannot  be  per- 
ceived. External  hernia  is  enveloped  with  all  the  layers  external  to 
the  cord  and  testicle,  and  also  by  the  peritoneum  of  the  sack ;  the  en- 
velope of  the  internal  hernia  is  less  by  the  cremaster  muscle  and  the 
common  sheath  coming  from  the  fascia  transversalis  ;  the  first  hernia 
glides  before  the  cord,  the  second,  a  little  on  the  inside  and  behind  it  ; 
nevertheless,  these  relations  of  the  hernias  with  the  spermatic  cord  are 


230  TOPOGRAPHICAL    ANATOMY. 

transitory  in  those  which  are  chronic,  and  consequently  cannot  serve 
as  a  guide  in  dividing  the  ring.  •  When  the  tumor  which  forms  a  her- 
nia is  large,  it  weighs  upon  the  testicle  and  wastes  it ;  varices  of  the 
spermatic  cord  have  the  same  effect  on  this  organ;  these  varices  are 
frequent ;  .the  absence  of  the  valves  in  the  veins  of  the  testicles,  their 
successive  division  and  union,  the  looseness  of  the  layers  which  cover 
them,  explain  this  frequency  on  the  two  sides,  but  the  relations  of  the 
sigmoid  flexure  of  the  colon,  with  the  veins  of  the  left  testicle,  is  the 
true  cause  of  the  more  common  appearance  of  varicocele  on  the  left 
side.  The  continuity  of  the  dartos  with  the  middle  cellular  tissue  of 
the  perineum,  explains  the  urinary  abscesses  which  always  occur  there 
in  ruptures  of  'the  urethra.  Hydrocele,  a  disease  of  this  region,  may 
affect  the  vaginal  tunic,  or  the  cord ;  we  do  riot  allude  to  that  caused 
by  the  infiltration  of  the  dartos.  The  first  extends  before  the  cord  and 
testicle,  which  are  situated  at  the  posterior  part  of  the  tumor  ;  hence, 
when  we  puncture  it,  we  must  introduce  .the  trocar  forward,  and 
direct  it  upward,  in  order  to  run  less  risk  of  injuring  these  parts. 
Hydrocele  of  the  cord  is  often  situated  in  an  old  herniary  sac,  the  neck 
of  which  is  obliterated,  in  a  cyst  formed  accidentally,  or  in  one  or  more 
of  these  sacs,  which  frequently  remain  on  the  neck  of  the  tunica  va- 
.  ginalis.  The  non-obliteration  of  the  neck  of  the  vaginal  tunic  explains 
the  phenomena  of  congenital  hydrocele  and  those  of  congenital  hernia. 
This  latter  is  often  produced  by  the  testicle  adhering  to  the  intestine 
before  its  descent ;  the  latter  is  then  necessarily  brought  down -with  it, 
when  it  passes  thro.ugh  the  inguinal  canal.  Various  swellings  of  the 
testicles  cause -peculiar  pains  connected  with  the  nerves- received  by 
the  diseased  organ ;  their  extirpation,  which  is  sometimes  required, 
presents  nothing  peculiar,  except  the  facility  with  which  it  is  performed, 
on  account  of  the  looseness  of  the  surrounding  cellular  tissue.  Before 
proceeding  to  this  operation,  we  -must  examine  the  abdominal  region, 
to  discover  the  state  of  the  lumbar  ganglions,  because  as  they  receive 
the  lymphatic  vessels  of  the  testicles,  these  ganglions  may  participate 
in  their  disease,  which  would  contra-indicate  an  operation.  .  Tubercles 
are  frequently  situated  in  the  epidydimis,  and  also  in  the  testicle,  but 
less  frequently ;  these  are  confounded  with  sarcocele,.and  may  perhaps 
be  cured,  although  slowly,  without  mutilation. 


2 .     REGION      OF      THE     PENIS. 

The  penis,  which  forms  this  region,  is  described  minutely  in  works 
on  descriptive  anatomy.  We  shall  merely  mention,  that  it  is  attached 
by  its  upper  part  in  front  of  the  symphysis  pubis,  and  that  along  its  in- 


REGION  OF  THE  PENIS.  .  231 

ferior  face,  is  a  prominence  which  belongs  to  the  urethra,  that  its  root 
is  trifurcated  and  enters  into  the  perineum,  that  its  loose  extremity  is 
rounded  and  formed  by  the  -glans,  the  point  of  which  presents  the 
meatus  urinarius,  the  contracted  opening  of  the  urethra,  that  the 
glans  is  lower  posteriorly,,  where  it  presents  a  groove  which  serves  for 
the  insertion  of  the  frenum  of  the  prepuce,  that  this  envelope  itself  is 
attached  to  the  glans  by  the  frenum,  it  is.  mucous  on  the  inside  and 
cutaneous' on  the  outside,  and  presents  an  opening,  which  generally 
gives  passage  to  the  glans,  and  is  separated  from  this  below  by  a  groove, 
where  are  found  glands  which  secrete  a  very  odoriferous  matter.* 
The  rounded  form,  the  size,  the-  length,  the  curved  direction  of  this 
organ,  must  not  be  mentioned  here. 

.  Structure.  —  1.  Elements,  This  region  is  formed  essentially  by  the 
cavernous,  body,  which  presents  inferiorly  a  groove,  in  which  the. 
urethra  is  situated:  the  elastic  membrane  which  confines  the  cavernous 
body,  presents  superiorly  a  small  sheath  for  the  dorsal  artery  and  nerve 
of  the  penis.  The  urethra  extends  through  the  whole  spongy  portion 
of  the  penis  ;  it  is  about  seven  inches  long,  and  is  dilated  below  the 
glans  to  form,  the  navicular  fossa;  the  spongy -tissue,  which  doubles 
on  the  outside  of  the  mucous  membrane  of  this  passage,  becomes  very 
abundant  anteriorly,  where  it  forms  the  glans.  The  arteries  of  this 
region  are  numerous;  they  come  from  the  superficial  and  deep 
branches  of  the  perineal,  and  also  from  the  crural  artery  •  the  first  form 
the  urethra!  branches  and  terminate  the  artery  of  the  septum  of  the 
dartos  ;  the  second  form  the  deep  and  dorsal  branches  of  the  cavernous 
body  ;  finally,  the  last,  which  are  two  on  each  side,  are  small,  and  ter- 
minate the  external  genital  arteries.  The  veins  of  the  region  follow 
the  course  of  the  arteries;  but  on  the  outside  of  this  point  the  dorsal 
veins  leave"  their  attendant  arteries  to  pass  under  the  symphysis  pubis ; 
the  dorsal  veins  differ  from  the  arteries,  as.  they  are  not  situated  in  the 
membrane  of  the  cavernous  body.  The  superficial  .lymphatic  vessels, 
and.  those  of  the  urethra,  go  to  the  inguinal  ganglions ;  the  deep  to 
those  of  the  pelvis.  The  nerves  come  from  the  superior  and  inferior 
branches  of  the  perineal  nerve.  The  sub-cutaneous  cellular  tissue  is 
loose,  that  which  unites  the  urethra  and  the  cavernous  body  is  very 
dense  ;  the  fat  is.  entirely  deficient ;  the  skin  is  remarkable,  for  its  fine- 
ness, and  is  destitute  of  hairs. 

2.  Relations.  The  relations  are  very .  simple.  Under  the  skin,  we 
find,  first,  a  loose  cellular  tissue,  in  which  ramify  the  veins,  the  super- 
ficial lymphatic  vessels,  the  inferior  nerves  and  their  lateral  arteries ; 
second,  more  deeply,  the  urethra  below  ;  third,  between  this  canal  and 

*  This  matter  is  secreted  very  abundantly  and  in  the  same  place  by  a  small  animal  of  the 
family  of  the  cervi,  and  constitutes  musk. 


232  TOPOGRAPHICAL  ANATOMY. 

the  cavernous  body,  the  arterial  branches  of  the  urethra,  situated  in 
the  membrane  of  the  cavernous  body  above,  the  dorsal  arteries  and 
nerves  ;  and  in  its  centre,  on  the  right  and  left  of  the  median  septum, 
the  deep  artery. 

Development.  This  region  is  formed  of  two  lateral  pieces,  which 
are  very  distinct ;  at  this  period,  the  penis  is  double,  as  in  serpents. 
This  separation  continues  but  for  a  short  time ;  the  parts  soon  begin 
to  unite  from  behind  forward,  and  from  the  dorsal  toward  the  inferior 
face  ;  a  law  of  evolution,  which  is  very  important,  and  which  had 
been  overlooked  in  regard  to  the  cavernous  body,  although  observed 
in  the  urethra. 

Varieties.  This  region  presents  numerous  individual  varieties  in 
respect  to  extent  and  volume  :  we  shall  mention  here  only  those  which 
affect  some  of  its  parts,  which  variations  may  be  considered  as  devia- 
.tions  in  development.  Sometimes  one  dorsal  artery  appears,  formed 
by  the  anastomosis  of  the  two  which  commonly  exist :  we  often  see 
a  branch,  which  leaves  the  pelvis,  under  the  symphysis  pubis,  and 
anastomoses  with  the  dorsal  artery,  or  forms  it  entirely ;  it  comes  from 
the  obturator  artery  :  this  variety  assimilates  the  arteries  to  the  veins. 

Pathological  and  operative  deductions.  The  region  of  the  penis 
may  be  arrested  in  its  development,  and  be  more  or  less  completely 
cleft :.  the  urethra  may  be  deficient,  or  terminate  in  the  centre  of  the 
region  by  a  superior  opening,  which  is  rare,  (epispadias,)  or  through 
an  inferior  opening,  which  is  more  frequent,  (hypospadias.}  The . 
development  of  the  penis  explains  sufficiently  the  rarity  and  frequency 
of  these  defects  in  the  union,  considered  in  its  back  or  superior  surface. 
The  penis  may  remain  in  the  rudimentary  state  without  an  urethra, 
and  resemble  the  clitoris:  on  the  other  hand,  the  median  union 
may  be  perfect  too,  the  urethra  may  be  closed  by  a  membrane :  the 
opening  of  the  prepuce  also  may  be  obliterated,  or  simply  too  narrow  : 
this  is  congenital  phymosis,  which  prevents  the  cares  required  by 
cleanliness,  and  thereby  disposes  to  cancer  of  the  penis :  this  anomaly 
requires  an  operation  :  the  fremim  of  the  penis  may  be  too  long  or  too 
short,  and  in  both  cases  it  must  be  divided.  Sometimes  this  region 
is  amputated :  Dupuytren,  in  a  very  remarkable  case,  has  removed  it 
to  the  perineum:  from  what  has  been  said,  we  can  readily  conceive 
that  eight  or  ten  arteries  must  be  tied  in  this  operation  ;  the  two  deep 
cavernous  arteries,  two  dorsal,  two  small  inferior  urethral,  and  some 
lateral  twigs  given  off  by  the  external  genital  arteries.  The  necessary 
collapse  of  the  erectile  body,  explains  the  precept  given  by  authors,  to 
remove  the  skin  largely  in  amputations  of  the  penis.  In  blenorrhagia, 
anatomy  and  experience  demonstrate,  that  the  ganglions  in  the  groin 
may  be  affected  sympathetically. 


ABDOMINAL  CAVITY,  233 


ARTICLE     i  i. 


ABDOMINAL       CAVITY. 

The  regions  which  have  been  described  circumscribe  a  cavity, 
which  contains  most  of  the  digestive  tube,  and  of  the  urinary  and 
genital  organs ;  it  is  the  abdominal  cavity,  the  largest  of  the 
splanchnic  cavities. 

This  cavity  is  oval ;  its  direction  varies  at  different  points  :  in  the 
supra-pelyie  portion,  its  axis  is  directed  from  above  downward,  from 
behind  forward,  and  a  little  from  left  to  right,  and  would  be  represented 
by  a  line  drawn  from  the  centre  of  the  diaphragm  towards  the  right 
pubic  spine,  an  oblique  direction,  which  depends  on  that  of  the  dia- 
phragmatic region,  which  is  itself  caused  by  the  base  of  the  thorax 
and  the  dorsal  portion  of  the  spine.  The  direction  of  the  pelvic  portion 
of  the  abdominal  cavity,  is  a  curve,  concentric  to  the  anterior  face  of 
the  sacrum  ;  and,  in  fine,  the  direction  of  the  whole  abdominal  cavity 
is  that  of  an  S  :  we  shall  mention,  hereafter,  the  effect  of  this  double 
curve  on  some  of  the  functions. 

The  limits  of  the  lower  part  of  the  abdomen  are  distinct ;  this,  how- 
ever, is  not  the  case  above}  as  may  be  seen  by  a  bare  inspection. 
This  cavity  is  interlaced,  in  some  measure,  with  that  of  the  thorax,  so 
that  the  former,  on  the  inside,  rises  much  above  the  place  where  the 
second  descends  on  the  outside  ;  this  arrangement  varies  according  to 
the  motions  of  the  wall  of  the  diaphragm  in  respiration ;  generally 
speaking,  in  the  deepest  inspiration,  the  abdominal  cavity  ascends  as 
high  as  the  eighth  dorsal  vertebra,  consequently  much  above  the  lower 
limits  of  the  pulmonary  cavities.  The  abdominal  cavity  rises  a  little 
higher  on  the  right  than  on  the  left. 

Contained  parts.  We  shall  consider,  as  belonging  to  this  cavity, 
only  the  organs  which  are  entirely  detached  from  its  parietes  ;  these 
are,  first,  the  different  parts  of  the  digestive  tube,  from  the  end  of  the 
esophagus  to  the  termination  of  the  rectum;  second,  the  kidneys, 
ureters,  and  bladder ;  third,  the  uterus  and  its  appendages  in  the 
female,  the  vasa  deferentia  and  vesiculae  seminales  in  the  male :  all 
these  parts  are  minutely  described  in  works  on  splanchnology,  so  that 
we  shall  only  mention  their  relations  :  all  are  covered  more  or  less 
perfectly  by  the  peritoneum,  the  arrangement  of  which  also  belongs  to 
descriptive  anatomy;  we,  however,  shall  briefly  recapitulate  it,  on 

30 


234  TOPOGRAPHICAL  ANATOMY. 

account  of  its  extreme  importance,  and  because  it  is  not  generally 
mentioned  methodically.  We  shall  at  first  state  this  fact,  that,  if  we 
except  the  bladder,  no  viscus  rests  against  the  anterior  and  lateral 
parietes  of  the  abdominal  cavity :  the  serous  membrane,  also,  passes 
there  very  simply,  only  with  the  various  adhesions  which  have  been 
mentioned:  all  the  abdominal  organs,  on  the  contrary,  rest  against 
the  posterior,  superior,  and  inferior  parietes,  to  which  they  are  united 
by  vessels  and  cellular  bands,  which  form  the  proper  pedicle  of  each 
of  them :  these  are  the  points  on  which  the  peritoneum  is  reflected  so 
many  times,  leaving  the  parietes  to  go  on  the  organs,  and  enveloping 
them  in  an  extent  which  varies  according  to  the  extent  of  the  surface, 
by  which  these  give  insertion  to  their  pedicle  :  this  accounts  for  the 
formation  of  the  mesenteries,  the  , uterine,  vesical  ligaments,  &c. : 
above,  where  the  organs  are  very  numerous,  where  all  have  not  only 
a  pedicle  which  unites  them  to  the  abdominal  wall,  but  also  secondary 
pedicles,  which  connect  them  with  the  adjacent  organs,  the  arrange- 
ment of  the  peritoneum  becomes  very  complex.  These  causes,  and 
particularly  the  existence  of  the  secondary  pedicles,  determine  the 
formation  of  the  gastro-hepatic,  splenic,  &c.,  epiploa,  and  of  the  pos- 
terior cavity,  which  they  circumscribe. 

The  arteries  of  the  abdominal  viscera  come  from  the  trunk  of  the 
aorta,  or  from  that  of  the  hypogastric  artery ;  all  the  branches  which 
are  detached  from  the  anterior  and  lateral  faces  of  the  former,  except 
the  diaphragmatic  and  .  spermatic,  go  to  this  part ; .  the  coeliac  trunk, 
which  belongs  to  the  liver,  spleen,  pancreas,  and  stomach  ;  the  superior 
mesenterie,  the  convexity  of  which  belongs  to  all  the  small  intestine, 
and  the  concavity  to  the  right  side  of  the  large  intestine ;  the  inferior 
mesenterie,  which  is  distributed  to  the  left  side  of  the  large  intestine 
to  its  termination,  the  capsular  and  renal  arteries.  All  the  internal 
and  anterior  branches  of  the  hypogastric  artery,  excepting  the  sub- 
pubic,  are  also  distributed  in  the  abdominal  cavity,  to  wit,  the  ter- 
mination of  the  middle  hemorrhoidal  and  vesical  arteries  in  the  male ; 
of  the  same,  and  of  the  uterine  and  vaginal  arteries  in  the  female.  At 
first,  all  the :  veins  follow  the  course  of  the  arteries ;  but  when  once 
united  in  large  trunks,  they  must  be  distinguished  into  two  orders ; 
some  of  them  still  attend  the  arteries,  those  of  the  urinary  and  genital 
organs ;  the  others,  those  of  the  alimentary  canal,  unite  in  one  trunk, 
the  vena  portae,  which  ascends  obliquely  on  the  right,  towards  the 
transverse  fissu're  of  the  liver,  where  it  divides  arterially.  An  enor- 
mous mass  of  lymphatic  ganglions  are  also  situated  in  the  abdominal 
cavity,  unconnected  with  its  parietes :  they  are  most  numerous  and 
remarkable  in  the  mesentery,  where  they  receive  the  chyliferous 
vessels  from  the  small  intestines  ;  they  occur  in.  all  the  folds  of  the 


ABDOMINAL  CAVITY.  *Si 

peritoneum,  where  they  receive  the  lymphatics  from  the  adjacent 
organs :  these  ganglions  are  more  numerous  superiorly  than  inferiorly. 
The  abdominal  cellular  tissue  is  abundant  and  very  loose  ;  the  same 
is  true  of  the  fat :  these  two  tissues  exist  particularly  between  the  two 
layers  of  the  mesentery,  in  the  epiploa,  &c. ;  in  all  these  points,  the 
vesicles  of  fat  are  arranged  in  ribands  along  the  vessels. 

2.  Relations.  The  relations  between  the  organs  situated  in  the 
abdominal  cavity  are  extremely  simple,  and. must  now  be  described, 
as  also  their  position  in  relation  to  the  wall  which  protects  them :  this 
knowledge  can  alone  enable  the  physician  to  resolve  this  problem,  viz. 
a  point  of  the  abdomen  being  wounded  deeply,  in  a  given  direction, 
what  organs  are  concerned  ?  and  reciprocally,  an  organ  having  been 
affected  in  a  point  of  the  abdominal  cavity  by  a  wounding  instrument, 
in  a  given  direction,  to  determine  what  part  of  the  abdominal  parietes 
must  necessarily  have  been  injured  ?  But  to  attain  this,  the  exami- 
nation must  be  circumscribed  ;  we  may,  however,  suppose  two  hori- 
zontal planes,  one  of  which  passes  under  the  edge  of  the  last  ribs,  and 
the  other  above  the  crests  of  the  ilia.  We  thus  obtain  three  sections ; 
the  first  is  called  the  epigastric,  the  second  the  mesogastric,  or  umbi- 
lical, and  the  third  the  hypo-gastric.  Two  antero-posterior  planes, 
drawn  vertically  from  the  centre  of  the  crural  arch  towards  the  base 
of  the  chest,  divide  each  of  these  regions  into  three  which  are  smaller  : 

'  ,  .  O  . 

the  epigastric  region,  into  the  hypochondria  on  the  sides,  and  the 
epigastrium  in  the  centre  ;  the  mesogastric  section,  into  the  flanks,  and 
the  mesogastrium ;  the  hypogastric,  into  the  iliac  regions,  and  the 
hypogastrium  ;  the  last  is  continuous  with  the  cavity  of  the  pelvis. 

1 .     The  parietes  of  the  epigastric  section  are  formed  in  the  centre, 
by  the  superior  angle  of  the  great  costo-iliac  region,  on  the  sides  and 
posteriorly,  directly  by  the  region  of  the  diaphragm,  but  the  base  of  the 
chest  and  the  costal .  region  descend  outward  and  backward  on  it. 
The  organs  contained  by  this  part  of  the  abdomen,  are  consequently 
protected  immediately  by  the  thorax,  hence  the  name  thoraca,  applied 
to  them  by  some  anatomists.     If  we  raise  in  one  piece  the  whole  an- 
terior wall  of  the  epigastric  region,  we  see  that  this  wall  is  free  from 
adhesions,  except  on  the  right,  Xvhere  the  suspensory  ligament  of  the 
liver  is  attached ;  then  in  the  cavity  itself  we  find  successively ;  the 
left  lobe  of  the  liver,  situated  before  the  gastro-hepatic  epiploon,  the 
end  of  the  esophagus,  the  pyloric  portion  of  the  stomach,  which  touches 
downward,  like  the  liver,  the  abdominal  wall  in  a  variable  extent,  by  its 
anterior  face  when  empty,  by  its  great  edge  when  filled.     Below  the 
epiploon  mentioned,  and  behind  the  stomach,  we  find  the  posterior 
cavity  of  the  epiploa,  next  the  fold  of  the  peritoneum,  which  forms  this 
cavity  posteriorly,  the  last  two  portions  of  the  duodenum,  the  pancreas 


236  TOPOGRAPHICAL  ANATOMY. 

imbedded  in  a  mass  of  cellular  tissue  filled  with  lymphatic  and  ner- 
vous ganglions,  situated  superiorly  adjacent  to  the  coeliac  trunk,  sur- 
rounded by  the  solar  plexus,  and  resting  on  the  superior  mesenteric 
vessels ;  below,  finally,  the  centre  of  the  posterior  abdominal  wall,  and 
its  large  vessels.  In  the  right  hypochondrium,  the  liver  adheres  to 
the  diaphragm,  forward,  upward,  and  backward,  and  fills  this  space  so 
exactly,  that  it  always  presents  itself  when  we  raise  its  anterior,  poste- 
rior, superior,  or  straight  parietes.  In  the  healthy  state,  the  liver  does 
not  leave  this  point,  but  when  it  is  morbidly  enlarged,  it  comes  to  the 
anterior  abdominal  wall:  the  gall-bladder,  when  distended,  always 
projects  a  little  beyond  the  sharp  edge  of  the  liver ;  then  also,  its  ante- 
rior face  touches  the  costo-iliac  region.  Under  the  liver  and  its  vesicle, 
we  find  the  first  portion  of  the  duodenum,  the  upper  extremity  of  the 
ascending  colon,  and  the  vascular  pedicle  which  connects  the  liver  to 
the  stomach  and  duodenum,  a  pedicle  formed  by  the  hepatic  artery 
anteriorly,  the  hepatic  canal,  the  cystic  canal,  and  the  origin  of  the  cho- 
ledochus  in  the  centre,  by  the  vena  portas  posteriorly,  and  also  by  some 
twigs  of  the  tri-splanchnic  nerve,  and  the  end  of  the  right  pneumo- 
gastric  nerve,  all  which  organs  are  situated  in  the  right  edge  of  the 
gastro-epiploic  epiploon,  before  the  hiatus  of  Winslow.  Directly  be- 
hind the  liver,  we  remark  above,  the  vena  cava  inferior,  which  projects 
a  little  from  the  posterior  wall  of  the  abdomen,  below,  the  upper  ex- 
tremity of  the  kidney,  with  its  capsule,  which  adheres  to  it  and  to  the 
liver.  The  left  hypochondrium,  on  the  other  side,  is  filled  by  the 
splenic  extremity  of  the  stomach  :  above,  however,  we  find  a  small  pro- 
longation of  the  left  lobe  of  the  liver,  which  advances  on  the  stomach ; 
this  latter  rests  posteriorly  on  the  spleen,  to  which  it  is  attached  by  the 
gastro-splenic  epiploon,  formed  of  four  layers,  two  anterior,  which 
comprise  between  them  the  short  vessels,  and  which,  by  a  small  pro- 
longation of  the  posterior  cavity  of  the  epiploa,  are  separated  from  the 
two  posterior  layers,  which  intercept  between  them  the  splenic  vessels 
and  the  tip  of  the  pancreas.  The  upper  extremity  of  the  descending 
colon,  the  left  kidney,  and  the  renal  capsule,  proceed  also  to  the  spleen, 
behind  this  part  of  the  stomach. 

2.  The  centre  of  the  ilio-costal  region,  and  the  lumbar  region,  form 
the  circumference  of  the  mesogastric  section,  which  is  continuous  at 
its  lower  part  with  the  hypogastric  section,  without  any  marked  line 
of  demarcation,  \but  it  is  separated  above  from  the  epigastric  section, 
by  the  root  of  the  transverse  meso-colon,  which  contains  in  its  centre 
the  third  portion  of  the  duodenum.  If  we  raise  the  anterior  and  late- 
ral parts  of  this  circumference,  we  find  it  loose  in  every  part,  since  we 
discover  from  before  backward  the  gastro-colic  epiploon,  concealing 
the  transverse  colon,  which  is  often  flexed  downward,  so  as  to  go  even 


ABDOMINAL  CAVITY.  237 

into  the  mesogastrium.  Below  these  parts,  we  observe  the  circumvo- 
lutions of  the  small  intestine,  attached  by  the  mesentery  to  the  posterior 
wall  of  the  abdomen,  the  obliquity  of  which  to  the  right  and  down- 
ward, gives  to  them  this  direction.  In  both  flanks,  the  lumbar  colon 
appears,  below  some  folds  of  the  small  intestine,  and  is  often  attached 
to  the  posterior  wall  of  the  abdomen  by  a  meso-colon,  but  generally,  it 
does  not  project  into  the  cavity  of  the  peritoneum,  but  passes  only  on 
its  anterior  face.  Finally,  the  kidney,  and  the  fat  whicfi  surrounds  it, 
appear  behind  the  lumbar  colon. 

3.  The  mesogastric  section  is  continuous  with  the  preceding,  and 
with  the  cavity  of  the  pelvis,  corresponds  to  the  lower  portion  of  the 
costo-iliac  wall,  to  the  iliac  and  lumbar  regions;  its  anterior  wall, 
which  is  always  free  from  adhesions,  being  raised,  we  see :  the  gastro- 
colic  epiploon,  the  lower  edge  of  which  descends  lower  on  the  left  than 
on  the  right,  below,  the  small  intestine,  which  exists  singly  in  the 
centre,  while,  on  the  sides,  we  find,  farther  on  the  right,  the  coecum, 
which  rarely  presents  a  meso-coecum,  but  is  generally  covered  only  with 
the  peritoneum  on  its  anteripr  face,  and  finally,  on  the  left,  the  sigmoid 
flexure  of  the  colon,  which  presents  the  same  arrangement,  but  more 
rarely. 

4.  The  cavity  of  the  pelvis,  the  circumference  of  which  has  been 
described  separately,  a  cavity  closed  inferiorly  by  the  perineum,  a  true 
abdominal  wall,,  contains  the  bladder,  anteriorly,  which  projects  but 
slightly  into  the  cavity  of  the  peritoneum,  with  which  it  is  covered 
almost  alone  posteriorly,  from  which  arrangement  it  glides,  in  order 
to  dilate,  between  the  serous  membrane  of  the  abdomen,  and  the  an- 
terior wall  of  the  pelvis  and  abdomen:  the  bladder,  when  slightly 
distended,  leaves  the  cavity  of  the  pelvis,  and  comes  into  the  hypogas- 
trium,  behind  the  anterior  wall  of  the  abdomen ;  sometimes  it  has 
proceeded  even  to  the  umbilicus,  to  which  its  superior  prolongation, 
the  urachus,  always  extends.     Behind  the  bladder,  we  find  the  two 
vasa  deferentia,  which  converge,  after  crossing  on  the  inside,  the  direc- 
tion of  the  ureters,  which  are  contiguous  to  the  sides  of  the  same  or- 
gan :  still  farther  back,  is  a  more  or  less  deep  peritoneal  depression, 
the  vesico-rectal  in  the  male,  the  vesico-vaginal  and  uterine  in  the 
female,  into  which  the  folds  of  intestine  sometimes  enter ;  we  next  find 
in  the  female ;  the  uterus,  the  vagina,  and  the  broad  ligaments,  which 
separate  the  pelvis  into  two  halves,  an  anterior  and  a  posterior ;  finally, 
nearer  the  sacrum,  a  peritoneal  depression,  which  varies  in  length, 
and  is  termed  the  vagino-rectal,  into  which,  also,  the  folds  of  the  small 
intestine  often  enter ;  in  the  two  sexes,  the  rectum  comes  the  last ;  it 
rests  against  the  sacrum,  and  is  attached  there  by  the  meso-rectum 


233  TOPOGRAPHICAL  ANATOMY. 

above,  while  below,  it  is  covered  by  the  peritoneum  only  anteriorly, 
where  it  enters  into  the  perineum. 

Development.  The  rudiments  of  the  principal  abdominal  organs, 
especially  those  of  the  small  intestine,  can  be  observed  before  the 
abdominal  cavity  exists  ;  the  latter  is  then  formed  upon  them,  and  the 
anterior  part  does  not  appear  till  at  a  late  period.  The  mesogastric 
region  is  found  first;  next,  the  hypogastric  and  the  pelvic ;  the  epi- 
gastric appears  last :  the  abdominal  cavity  is  blended  with  that  of  the 
umbilical  cord,  in  the  early  months :  it  is  considerably  large  compared 
with  the  other  splanchnic  cavities,  a  fact  which  is  connected  with  the 
great  development  of  the  parts  it  contains :  its  parietes  are  proportion- 
ally very  thin.  At  birth,  the  gastro-colic  epiploon  does  not  exist ;  it  is 
formed  by  two  layers  which  arise  separately,  one  from  the  great  curve 
of  the  stomach,  the  other  from  the  arch  of  the  colon ;  at  two  years,  the 
loose  edge  of  these  two  layers  unite,  and  the  posterior  cavity  of  the 
epiploon,  which  was  previously  open  inferiorly,  is  closed  in  this  point. 
At  birth,  there  is  no  trace  of  fat  in  the  abdomen,  and  the  size  and  rela- 
tions of  certain  organs  differ  from  what  has  been  stated  :  the  liver  fills 
the  epigastrium  entirely,  leaving  on  the  left  side  a  small  space  for  the 
Upper  extremity  of  the  spleen  and  stomach  :  the  stomach  is  so  crowded 
by  the  liver  in  very  young  fetuses,  that  it  descends  perpendicularly  into 
the  left  flank.  The  liver  descends  into  the  mesogastrium,  and  even  into 
the  hypogastrium,  and  is  in  relation  with  the  anterior  wall  of -the  belly  ; 
the  intestines  are  crowded  towards  the  spine,  and  are  no  where  covered 
anteriorly  by  the  epiploon,  which  does  not  exist.  At  first,  the  co3cum 
is  situated  in  the  left  flank ;  next,  in  the  mesogastrium,  on  the  right 
flank ;  and  finally,  at  eight  months,  into  the  right  iliac  region,  so  that 
the  large  intestine  is  at  first  only  descending,  then  transverse  and  de- 
scepding,  and  finally  ascending,  transverse,  and  descending.  The 
bladder,  the  rectum,  and  all  the  genital  organs,  are  at  first  situated  out 
of  the  pelvis,  and  advance  into  the  hypogastrium,  preserving  the  rela- 
tions of  adult  age.  In  the  earlier  periods,  also,  the  bladder  is  -continu- 
ous with  the  urachus,  which  passes  out  through  the  umbilicus ;  the 
kidneys,  which  are  large,  are  united  on  the  median  line  by  a  prolon- 
gation of  their  substance  ;  their  form  is  uneven.  Finally,  the  testicles 
occupy,  successively,  the  lumbar  region,  below  the  kidneys ;  then  the 
different  points  of  the  inner  edge  of  the  iliac  fossa,  in  which  they  glide 
before  the  iliac  .vessels,  at  least  unless  prevented  by  some  abnormal 
adhesions:  at  birth,  the  testicle  is  situated  out  of  the  abdominal 
cavity.  Until  puberty,  the  proportional  development  of  the  abdominal 
cavity,  especially  that  of  its  upper  portion,  is  considerable  ;  but  at  this 
period,  the  proportions,  which  have  served  as  the  basis  of  our  exami- 
nation, are  seen,  its  pelvic  portion,  hitherto  the  most  rudimentary  part 


ABDOMINAL  CAVITY.  239 

of  the  cavity,  enlarges  very  much  ;  then,  also,  the  sexual  differences  in 
this  region  appear  more  strongly :  in  the  young  girl,  the  pelvic  portion 
enlarges,  especially  the  upper  pelvis,  which  becomes  the  largest  point. 
This  latter  arrangement  of  the  abdominal  cavity,  and  the  diminution 
of  its  capacity,  above  and  below  the  great  pelvis,  gives  it  internally  the 
form  of  a  basin  :  in  the  young  man,  on  the  contrary,  the  epigastric 
region  is  enlarged,  and  the  internal  cavity  has  the  form  of  a  hollow 
cone,  the  base  being  situated  superiorly.  At  puberty,  but  little  fat  is 
as  yet  found  around  the  abdominal  organs  ;  but  at  the  age  of  thirty- 
five  to  forty,  it  is  deposited  in  great  quantities,  especially  in  some  indi- 
viduals, and  forms  long  masses  along  the  blood-vessels.  This  increase 
of  fat  dilates  the  cavity  considerably,  in  which  also  the  intestines  are 
pressed  upon  more  forcibly  for  the  same  reason  ;  if,  in  these  cases,  a 
leanness  rapidly  supervenes,  the  viscera  are  no  longer  sufficiently  sus- 
tained. In  very  aged  persons,  the  fat  of  the  abdominal  cavity  is  often 
very  abundant,  and  exists  there  exclusively. 

Varieties.  Besides  the  sexual  varieties  already  mentioned,  the  ab- 
dominal cavity  is  carried  farther  backward  in  the  female  than  in  the 
male,  which  depends  on  the  greater  curve  of  the  lumbar  region  in  the 
former. 

Those  individuals  in  whom  the  abdominal  viscera  are  transposed, 
present  in  the  right  part  of  the  abdomen  the  relations  mentioned  as 
belonging  to  its  left  part,  and  reciprocally.  Sometimes  we  find  a  single 
kidney  situated  before  the  spine  :  several  years  since,  we  found  in  a 
cadaver  the  right  kidney  situated  in  the  cavity  of  the  pelvis.  During 
pregnancy,  the  abdominal  cavity  of  the  female  experiences  remarkable 
changes  in  its  form,  capacity,  direction,  the  relations  of  its  organs,  and 
its  circulation.  In  the  first  month,  it  seems  to  contract,  and  its  parietes 
to  collapse  ;  at  a  later  period,  we  observe  opposite  changes.  On  ac- 
count of  the  resistance  of  the  circumference  of  the  pelvis,  in  which  the 
uterus  is  at  first  developed,  when  this  has  acquired  a  certain  size,  it 
extends  upward,  and  goes  into  the  supra-pelvic  part  of  the  abdominal 
cavity,  which  it  dilates  anteriorly,  and  thus  removes  from  the  axis  of 
the  abdomen  its  anterior  obliquity.  The  dilated  uterus  is  situated 
entirely  anteriorly,  behind.the  anterior  wall  of  the  abdomen  ;  it  presses, 
on  the  side  of  the  vertebral  column,  the  small  intestine,  and  the  epi- 
ploon :  this  latter,  however,  sometimes,  but  rarely,  remains  in  front  of 
it.  The  uterus,  also,  crowds  the  diaphragm  upward,  and  raises  it  to 
the  sixth  dorsal  vertebra :  on  the  other  hand,  all  the  peritoneal  folds 
of  the  uterus  disappear,  the  peritoneum  no  longer  descends  in  the 
cavity  of  the  pelvis,  the  bladder  and  rectum  are  very  much  compressed, 
and  fulfil  their  functions  with  difficulty ;  the  uterus,  also,  is  inclined 
to  the  side,  and  most  commonly  to  the  right  side ;  its  inclination  de- 


240  TOPOGRAPHICAL  ANATOMY. 

pends  on  the  projection  of  the  vertebral  column  ;  its  right  obliquity  is 
produced,  according  to  Chaussier,  by  the  shortness  of  the  supra-pubic 
cord  on  the  right  side.  Notwithstanding  this  enlargement  of  the  ab- 
dominal cavity,  the  viscera  are  pressed  upon  with  unusual  force,  and 
consequently  form  hernias  more  easily,  as  the  distended  and  thin  pa- 
rietes  have  lost  much  of  their  resistance.  The  normal  irritation 
which  is  situated  in  the  uterus  at  this  period,  solicits  a  greater  quantity 
of  blood  into  the  whole  inferior  vascular  system,  and  particularly  into 
its  own  ;  all  the  vessels  of  this  organ  are  dilated,  its  structure  is  modi- 
fied, &c.  &c. 

Uses.  In  the  cavity  of  the  abdomen,  the  processes  of  chymification, 
the  formation  and  the  absorption  of  the  chyle,  the  secretion  of  the 
urine,  &c.,  take  place,  to  which  functions  this  cavity  also  contributes ; 
in  fact,  the  abdominal  parietes  press  more  or  less  forcibly  upon  the 
viscera,  and  indirectly  upon  their '  contents  ;  this  pressure  upon  each 
part  of  them,  solicits  them  toward  the  axis  of  the  cavity,  and  in  such 
a  manner,  that  they  are  always  propelled  towards  the  anterior  part  of 
the  circumference  of  the  pelvis,  and  particularly  toward  the  right 
groin  ;  this  obliquity  is  in  a  direct  ratio  with  the  inclination  of  the  axis 
of  the  upper  part  of  the  abdominal  cavity.  The  viscera  contained  in 
the  pelvis  are  protected  from  this  effect  of  the  parietes  by  the  direction 
of  the  axis  of  that  part  of  the  cavity  which  receives  them,  which  direc- 
tion is  such  that  this  axis  does  not  blend  with  that  of  the  supra-pelvic 
part.  This  protection  of  the  organs  of  the  pelvis  against  the  constant 
action  of  the  abdominal  parietes,  is  connected  with  their  functions  of 
serving  for  the  receptacle  of  the  urine,  of  the  fetus,  &c.  Farther,  in 
cases  where  these  contain  parts  that  are  to  be  expelled,  we  naturally 
incline  forward  the  upper  part  of  the  abdominal  cavity,  so  as  to  unite 
the  axes  of  its  pelvic  and  supra-pelvic  portions  ;  the  contractile  action 
of  the  parietes  is  then  more  or  less  increased  by  these  efforts,  and  ex- 
tends toward  the  base  of  the  pelvis,  acts  upon  all  the  organs,  and  is 
transmitted  directly  to  the  contents,  which  soon  pass  in  this  direction. 
This  is  the  reason  why  we  lean  forward,  when  the  urine  or  the  feces 
are  expelled  with  difficulty.  During  labor,  also,  the  position  of  the 
female  should  be  regulated  by  these  important  ideas. 

When  the  diaphragmatic  wall  of  the  abdominal  cavity  is  depressed, 
the  anterior  and  lateral  parietes  yield ;  when  it  rises,  the  last  contract, 
so  that  the  abdomen  always  preserves  the  same  capacity.  The  action 
of  the  muscles  is  independent  of  these  motions  of  the  anterior  and 
lateral  parietes,  they  in  fact  yield  and  are  restored  by  the  elasticity 
alone.  In  efforts,  especially  in  those  of  vomiting,  the  case  is  different ; 
the  diaphragmatic  and  anterior  walls  of  the  abdomen  contract  together, 


ABDOMINAL  CAVITY.  241 

the  abdominal  cavity  is  contracted,  and  the  viscera  are  subjected  to 
considerable  pressure. 

Pathological  and  operative  deductions.  We  have  already  men- 
tioned the  openness  of  the  abdomen  externally,  in  consequence  of  the 
imperfect  development  of  its  parietes ;  this  division  may  be  confined 
to  them,  or  it  may  extend  to  some  of  the  deep  organs.  The  anterior 
fissure  of  the  pelvic  part  of  the  abdomen  also  causes  the  division  of  the 
bladder  anteriorly ;  hence,  extrophia  of  this  organ,  a  deviation  of 
formation  already  mentioned  in  another  place.  The  different  abdo- 
minal viscera  are  also  subject  to  imperfections,  which  we  shall  not 
mention  here,  as  they  belong  to  descriptive  anatomy ;  the  most  re- 
markable are  those  which  consist  in  a  more  or  less  perfect  interruption 
of  the  intestinal  canal.  Most  authors  think  that  these  deviations  of 
formation  are  produced  by  a  partial  obliteration  and  atrophy ;  in  fact, 
in  certain  cases,  we  find  between  the  two  extremities  or  cul-de-sac  of 
the  intestine,  a  cellular  filament,  which  may  be  considered  as  the 
remnant  of  the  obliterated  canal ;  but  in  some  cases,  we  find  no  con- 
nexion, no  relation  of  position  between  these  two  parts;  hence,  it 
follows,  that  it  is  difficult  not  to  admit  that  the  obliteration  of  the  in- 
testinal canal  is  not,  in  all  these  cases,  the  principle  of  this  anomaly. 
Can  this  latter  state  confirm  the  opinion  of  those  who  think  that  the 
intestinal  canal  proceeds  from  the  mouth  and  from  the  anus  by  two 
prolongations,  which  meet,  and  generally  unite  in  the  abdomen  ?  Be 
this  as  it  may,  we  have  a  fetus  which  presents  in  the  small  intestine 
an  instance  of  each  of  the  interruptions  mentioned ;  one  is  perfect,  and 
no  marks  of  an  ancient  continuity  between  the  corresponding  ends 
remain  ;  the  other  is  imperfect,  and  a  very  thin  cellular  filament  still 
marks  the  continuity.  Wounds  of  the  abdominal  cavity,  or  penetrating 
wounds  of  the  abdomen,  are  generally  very  severe ;  the  most  simple 
usually  give  rise  to  a  slight,  peritonitis ;  these  wounds  may  be  compli- 
cated with  bloody,  serous,  or  purulent  effusions,  with  lesions  of  the 
viscera,  and  even  with  emphysema.  When  a  small  quantity  of  blood 
is  effused  into  the  abdomen,  it  obeys  the  law  of  gravity,  and  goes  toward 
the  base  of  the  anterior  abdominal  wall,  and  particularly  toward  the 
right  inguinal  region,  Sabatier  has  remarked,  that  the  contractile  re- 
action of  the  abdominal  parietes  is  one  cause  of  this  phenomenon;  we 
might  also  add,  that  the  direction  of  the  axis  of  the  supra-pelvic  part 
of  the  abdomen  is  exactly  that  followed  by  the  effused  matters  in  going 
downward.  When  the  organ,  which  by  its  injury  supplied  the  effused 
material,  is  near  the  external  wound,  the  blood,  or  other  fluid  matters, 
often  escape  through  this  wound,  instead  of  falling  into  the  cavity  of 
the  peritoneum.  This  phenomenon  is  very  simple  ;  in  fact,  the  fluids, 
on  leaving  their  passages  or  reservoirs,  tend  to  go  to  that  part  where 

31 


242  TOPOGRAPHICAL    ANATOMY. 

there  is  the  least  resistance  ;  but  it  is  evident  they  will  be  subjected  to 
no  pressure  on  the  outside  of  the  abdomen,  while  on  the  inside  they 
will  have  to  support  all  that  of  the  contractile  parietes  of  this  cavity. 
This,  also,  is  the  reason  why  we  have  seen  wounds  complicated  with 
the  opening  of  certain  vessels  and  of  other  abdominal  organs,  although 
their  respective  fluids  were  not  effused  ;  the  circumstances,  however, 
are  not  always  so  fortunate,  and  effusions  of  bile,  urine,  and  of  food, 
into  the  abdomen,  are  not  unfrequent,  in  wounds  of  the  gall-bladder, 
bladder,  and  stomach.     On  account  of  the  constant  action  of  the  ab- 
dominal parietes,  their  wounds  cannot  be  kept  in  place  without  the 
employment  of  the  quilled  suture  ;  wounds  in  the  intestinal  canal  also 
require  a  special  suture,  although  we  cannot  hope  for  a  regular  cica- 
trization, since  the  edges  of  these  wounds  are  constantly  separated  and 
thrown  outward  by  the  action  of  the  muscles.     Farther,  the  suture  to 
be  employed  is  the  interrupted  suture  modified  by  Beclard.     If,  on  the 
contrary,  the  intestine  is  entirely  divided,  we  must  invaginate  the  lower 
end  in  the  upper  end,  taking  care  first  to  draw  this  into  itself.     This 
mode,  invented  by  Joubert,  presents  the  great  advantage  of  the  contact 
of  the  serous  membranes  of  both  extremities  of  the  divided  intestinal 
canal,  and  a  prompt  union  is  obtained,  after  which  there  remains  in 
the  intestine  only  a  floating  fold,  which  may  be  compared  to  a  large 
valvula  connivens.     These  different,  intestinal  sutures,  however,  can- 
not be  admitted,  except  where  the  injured  part  has  left  the  abdominal 
cavity ;    to  look  for  it  in  the  abdomen,  would   expose   to   irritation. 
Finally,  in  wounds  of  the  abdominal  cavity,  emphysema  may  appear, 
as  we  have  remarked  ;  it  is  produced  in  the  following  manner  :  when 
the  diaphragm  reascends  in  the  normal  state,  it  is  followed,  as  we 
have  seen,  by  the  anterior  and  lateral  abdominal  wall  which  rises  ;  and 
thus  the  space  which  the  first  tends  to  form  on  the  side  of  the  abdo- 
men, does  not  exist ;  but  when  the  peritoneal  cavity  is  opened,  the  air 
may  enter  into  it  during  the  elevation  of  the  diaphragm,  especially  if 
this  takes  place  rapidly ;  next,  then,  this  elastic  fluid  is  pressed  by  the 
depression  of  the  diaphragm,  and  must  necessarily  tend  to  leave  it 
altogether,  or  to  enter  into  the  cellular  tissue,  if  the  wound  on  the 
outside  be  narrow.     We  must  however  admit,  that  in  most  cases  of 
wounds  of  the  abdomen,  where  emphysema  has  been  observed,  the 
pulmonary  and  peritoneal  cavities  were  injured,  which  injury  was 
favored,  as  we  have  said,  by  the  interlacing  of  the  chest  and  abdomen. 
We  do  not  speak  of  the  special  organs  which  may  be  wounded  in 
different  affections  of  the  abdomen  ;  the  relations  which  have  been 
mentioned  state  this  sufficiently.     The  internal  viscera  may  be  injured 
without  a  wound  of  the  peritoneum.     Richerand  has  proved  by  expe- 
riment, that  in  falls  from  a  lofty  place,  the  liver  is  generally  contused  ; 


ABDOMINAL  CAVITY.  243 

this  is  probable,  from  its  softness  and  size :  hence  the  solution  of  the 
problem,  which  had  been  looked  for  in  vain  by  Bertrandi  and  Pouteau, 
viz.  to  determine  the  cause  of  abscesses  of  the  liver  in  wounds  of  the 
head. 

A  greater  or  less  portion  of  the  mass  of  intestines  may  descend  in  her- 
nia, and  then  the  abdominal  cavity  contracts  in  a  proportional  degree ; 
this  accounts  for  the  difficulty  in  reducing  old  and  very  large  hernias. 
When  the  epiploon  and  the  small  intestine  form  a  hernia  together,  the 
first  is  always  situated  anteriorly ;  this  is  also  the  position  it  normally 
occupies  in  the  abdominal  cavity ;  hence  the  precept  in  reducing  these 
parts,  to  act  first  on  the  intestine,  then  on  the  epiploon ;  if  any  other 
course  were  pursued,  we  should  run  the  risk  of  turning  one  of  them 
around  the  other,  and  of  producing  an  internal  strangulation.  Ab- 
scesses of  the  liver  may  open  into  the  chest,  if  they  are  developed  on 
its  convex  face  ;  those  on  the  opposite  face  always  point  in  the  stomach, 
the  duodenum,  or  the  arch  of  the  colon,  of  which  we  can  easily  form 
an  idea,  if  we  remember  the  relations  of  the  organs  of  the  right  hypo- 
chondrium ;  other  abscesses  of  the  liver  sometimes  raise  the  ilio-costal 
region,  and  open  on  the  outside  ;  if  in  these  kinds  of  abscesses  we  think 
proper  to  make  an  artificial  opening,  we  must  use  the  caustic  potash ; 
if  we  use  the  lancet,  we  might  proceed  beyond  the  adhesions  of  the 
pouch,  and  open  the  peritoneum ;  the  potash  has  not  this  inconveni- 
ence, it  acts  by  forming  an  eschar,  around  which  adhesions  occur 
when  it  sloughs  off.  The  same  course  must  be  pursued,  to  open  the 
gall-bladder,  when  enormously  distended  by  calculi ;  biliary  cistotomy 
cannot  be  performed  by  a  cutting  instrument,  except  by  a  surgeon  en- 
tirely destitute  of  anatomical  and  pathological  knowledge  ;  this  is  not 
true  of  the  puncture,  or  of  the  incision  of  the  neck  of  the  urinary 
bladder,  to  evacuate  urine,  or  extract  the  calculi  contained  in  it ;  these 
operations  are  founded  upon  our  remarks  upon  the  anterior  relations 
of  the  bladder  with  the  anterior  abdominal  wall,  relations  which  are 
established,  independent  of  the  peritoneum.  This  arrangement  exists 
directly  above  the  pubisj  and  these  operations  should  be  performed 
there  ;  we  do  not  speak  of  the  layers  of  the  costo-iliac  region,  which 
exist  on  the  raphe,  and  which  are  interested;  we  have  already  mention- 
ed them ;  behind  the  abdominal  wall,  we  cut  only  a  very  loose  cellulo- 
adipose  tissue,  and  the  anterior  wall  of  the  bladder ;  for  puncturing 
it,  the  curved  trocar  of  Cosme  is  the  best  instrument  to  use ;  it  allows 
us  to  reach  the  bladder  even  very  low  behind  the  pubisj  without  touch- 
ing its  posterior  wall.  In  the  high  operation  of  lithotomy,  if  the  sound  is 
carried  through  an  opening  previously  made  in  the  perineum,  its  tip 
easily  rubs  against  the  anterior  wall  of  the  bladder,  which  is  difficult 
to  be  accomplished,  if  this  sound  is  simply  introduced  into  the  urethra ; 


244  TOPOGRAPHICAL    ANATOMY. 

this  single  reason  is  sufficient  to  show  all  the  importance  of  the  open- 
ing in  the  perineum,  made  in  the  high  operation  of  lithotomy,  which 
has  been  doubted  by  some  persons  ;  another  reason  why  this  precau- 
tion should  not  be  neglected  is,  it  prevents  the  infiltration  of  urine,  the 
discharge  of  which  is  facilitated  by  its  sloping  position.  The  infiltra- 
tions which  may  occur,  are  much  more  serious,  as  they  extend  very 
rapidly  into  the  sub-peritoneal,  pelvic,  and  perineal  tissues,  which  are 
extremely  loose,  as  we  have  seen.  The  abdominal  organs,  without 
constituting  an  external  hernia,  may  be  strangulated  in  different  ways, 
in  the  abdominal  cavity,  by  bridles,  invaginations,  or  by  the  twisting 
of  some  parts  around  others.  We  have  seen  at  La  Charite,  a  very 
remarkable  instance  of  this  last  kind  of  internal  strangulation ;  most 
of  the  fold  of  the  small  intestine,  after  ascending  on  the  right  into  the 
epigastric  region,  had  come  through  the  hiatus  of  Winslow,  into  the 
posterior  cavity  of  the  epiploa,  from  which  it  emerged  through  a  nar- 
row abnormal  opening  in  the  transverse  meso-colon,  which  opening 
had  pressed  forcibly  upon  the  intestine,  and  had  caused  sphacelus.  In 
a  case  where  a  patient  presents  all  the  symptoms  of  internal  strangu- 
lation, must  we,  guided  by  this  alone,  perform  gastrotomy,  open  the 
abdominal  cavity,  and  look  for  the  strangulated  part,  to  relieve  the 
symptoms?  This  operation  is  rejected  by  sound  practice,  because 
symptoms  analogous  to  those  of  strangulations,  may  be  produced  by 
other  diseases ;  and  also  because,  if  we  were  certain  a  strangulation 
existed,  we  must  determine  its  situation  and  nature,  before  operating, 
which  is  generally  impossible.  Gastrotomy,  applied  to  the  treatment 
of  internal  strangulations,  would  be  proper  only  where,  in  a  particular 
case,  the  symptoms  continued,  after  the  hernia  had  been  reduced  in  a 
mass,  and  we  have  reason  to  believe  the  strangulation  existed ;  but 
then  its  situation  and  nature  are  known.  From  the  lateral  deviation 
of  the  uterus  during  pregnancy,  one  of  its  edges  becomes  a  little  ante- 
rior, and  as  the  very  dilated  trunks  of  the  uterine  arteries  are  situated 
in  these  points,  it.  has  been  advised,  to  avoid  hemorrhage,  when  cutting 
the  uterus,  in  the  Cesarean  operation,  not  to  operate  on  the  median 
line.  Taking  into  view  the  severity  of  wounds  of  the  uterus,  and  the 
facility  of  reaching  the  vagina,  above  the  superior  strait  of  the  pelvis, 
in  the  latter  months  of  gestation,  Baudelocque*  has  proposed  in  the 
Cesarean  operation,  to  open  the  vulvo-uterine  passage,  after  making 
in  the  costo-iliac  region,  near  the  fold  of  the  right  groin,  an  incision, 
oblique  from  the  flank  to  the  pubis ;  he  advises  to  divide  the  perito- 
neum ;  perhaps  it  would  be  more  advantageous,  only  to  separate  it 

*  This  operation  was  proposed  before  Baudelocque,  by  Prof.  Riegan,  of  Giessen,  and  Profl 
Physic,  of  Philadelphia,  and  was  also  mentioned  by  Dubois,  in  his  course. 


ABDOMINAL  CAVITY.  245 

from  the  iliac  fossa,  which  is  easy,  as  in  the  latter  periods  pf  pregnan- 
cy, the  peritoneum  of  the  cavity  of  the  pelvis,  as  has  been  mentioned, 
ascends  to  the  superior  strait,  being  drawn  upward  by  the  enlarged 
uterus.  M.  Baudebcque,  however,  has  not  abandoned  this  process. 
The  selection  of  the  right  portion  of  the  abdomen  for  the  operation,  is 
founded  on  the  observation  of  the  right  lateral  deviation  of  the  uterus. 
After  attacks  of  peritonitis,  the  abdominal  viscera  adhere  intimately, 
by  which  their  motions  are  more  or  less  impeded.  In  diaphragmatic 
peritonitis,  a  diaphragmatic  pleurisy  is  often  seen  consecutively,  and 
vice  versa ;  this  depends  on  the  common  source  from  which  the  vessels 
of  the  peritoneum  and  of  the  diaphragmatic  pleura  proceed.  When 
serum  is  effused  into  the  abdomen,  which  constitutes  ascites,  sometimes 
it  occupies  the  whole  cavity,  and  sometimes  it  is  situated  in  a  circum- 
scribed point.  We  have  observed  dropsy  of  the  single  posterior  cavity 
of  the  epiploa ;  this  variety  of  encysted  ascites  must  be  attended  with 
very  great  derangement  in  the  functions  of  the  stomach  ;  in  fact,  this 
viscus  is  crowded  forward,  and  is  flattened  against  the  anterior  wall 
of  the  abdomen.  There  are  also  many  other  encysted  dropsies  of  the 
abdomen,  among  which  we  distinguish  principally  that  of  the  ovary, 
in  which  several  pouches  generally  exist,  each  of  which  contains  a 
fluid,  distinct  in  respect  to  its  physical  and  chemical  properties.  This 
disease,  which  is  often  attended  with  other  organic  affections  of  the 
ovary,  is  rarely  situated  on  both  sides  at  once  ;  it  may  be  recognised 
by  its  commencing  near  one  of  the  iliac  regions ;  but.  at  a  later  pe- 
riod, the  tumor  fills  the  whole  of  the  abdominal  cavity,  and  can  with 
difficulty  be  distinguished  from  ascites.  In  dropsy  of  the  ovary,  the 
puncture  should  be  made  on  the  side  affected ;  in  common  ascites, 
the  left  side  is  generally  selected,  because  the  liver  often  impedes 
the  operation  on  the  other.  When  adhesions  between  the  epiploon,  or 
the  intestines  and  the  abdominal  wall  are  suspected,  we  must  divide 
this  with  a  bistoury,  and  when  the  serum  is  evacuated,  we  must  apply 
a  bandage  to  the  abdomen,  to  support  the  vessels  of  the  cavity,  and  to 
prevent  their  engorgement  with  blood,  and  consequently  to  oppose  in- 
flammation, which  would  easily  supervene  without  this  precaution, 
A  body  bandage  is  also  applied  to  the  lying-in  female  for  the. same 
reason,  and  also  to  facilitate  the  contraction  of  the  parietes  of  the  ab- 
dominal cavity.  The  attacks  of  peritonitis,  which  often  supervene 
under  these  circumstances,  are  produced  by  the  stagnation  of  blood  in 
the  abdominal  vessels ;  this  stagnation  is  much  more  easy,  as  these 
vessels  have  less  support  after  parturition,  and  were  previously  the 
seat  of  a  very  active  circulation,  which  may  be  considered  as  con- 
tinued abnormally ;  when  the  small  intestine  descends  in  hernias,  it  is 
seen  most  frequently  on  the  rightx  on  account  of  the  direction  toward 


246  TOPOGRAPHICAL  ANATOMY. 

this  side  imparted  to  it  by  the  mesentery ;  when,  on  the  contrary,  it  is 
the  epiploon,  it  occurs  most  frequently  on  the  left,  on  account  of  the 
greater  length  of  its  lower  edge  on  this  side.  The  vascular  connexion 
of  certain  abdominal  viscera  with  the  posterior  and  perineal  parietes 
of  the  abdomen,  explains  the  good  effect  produced  by  the  application 
of  leeches,  in  diseases  of  this  part. 


PART    II. 


OF      THE      LIMBS. 

THE  limbs  are  appendages  or  articulated  prolongations  of  the  trunk  : 
they  exist  in  most  animals,  and  in  the  vertebrated  classes  are  never 
more  than  four ;  in  the  invertebral  genera,  they  are  much  more 
numerous. 

In  man,  the  limbs  have  been  distinguished  into  upper  and  lower ; 
but  this  distinction  is  convenient  for  him  alone  ;  hence,  anatomists 
have  long  proposed  to  separate  them,  and  term  them  according  to  the 
part  of  the  trunk  from  which  they  seem  to  emanate,  the  thoracic  and 
the  abdominal.  The  limbs  might  have  been  described  when  speaking 
of  the  thorax  and  abdomen  ;  but  we  should  then  have  neglected  the 
analogies  they  present,  and  consequently  should  have  been  unable  to 
have  spoken  of  them  generally,  the  only  mode  of  simplifying  descrip- 
tion, and  of  avoiding  tedious  repetitions.  Farther,  whatever  may  be 
our  ideas  on  this  subject,  we  cannot  but  observe  the  numerous  analo- 
gies, and  also  the  marked  differences,  between  the  limbs.  The  first 
will  be  mentioned  in  the  general  description  ;  the  second  will  form 
our  special  remarks  upon  the  same  subject  The  limbs  are  arranged 
symmetrically,  so  that  those  on  one  side  are  perfectly  similar  to  those 
on  the  opposite  side,  except  that  those  on  the  right  side  are  larger  than 
those  on  the  left.  The  limbs  have  the  form  of  truncated  pyramids, 
the  base  of  which  rests  on  the  trunk,  and  the  point  of  which  is  loose, 
and  divided  into  five  distinct  segments.  They  are  remarkable  in  our 
species  for  their  freedom  ;  this  contributes  to  render  them  elegant  and 
moveable. 


LIMBS.  247 

Their  direction  varies  singularly  ;  to  study  them,  we  suppose  them 
placed  perpendicularly ;  their  length  is  nearly  the  same ;  this  depends 
on  various  circumstances,  which  will  be  mentioned  hereafter.  Each 
limb  is  formed  of  four  great  principal  divisions,  united  by  joints,  which 
are  generally  enlarged,  and  form  important  regions. 

Structure.  —  1.  Elements.  In  the  limbs  we  find ;  a  central  skeleton, 
formed  by  long  bones,  united  by  articulations,*  which  are  more  movea- 
ble  on  the  side  of  the  trunk  than  on  the  opposite  extremity ;  some 
muscles  forming  two  layers ;  a  superficial,  with  long  and  very  con- 
tractile fibres  ;  the  other  deep,  with  short  fibres,  which  have  less  con- 
tractile power,  which  is  attached  to  the  bones  :  all  are  surrounded  with 
a  very  strong  and  almost  inextensible  aponeurosis,  which  sends  toward 
the  bones,  in  the  muscular  interstices,  some  fibrous  septa,  on  which 
the  muscles  are  inserted,  which  are  thus  surrounded  with  real  sheaths  ; 
the  arteries,  coming  from  a  single  trunk,  situated  at  the  upper  part 
of  the  limb,  and  connected  by  some  anastomoses  to  those  of  the  trunk  ; 
some  superficial  and  deep  veins  go  toward  the  heart,  by  a  single 
branch,  all  of  which  are  provided  with  internal  valves,  which  are 
more  numerous  in  the  deept  than  in  the  superficial  veins  ;  some  lym- 
phatic vessels,  which  are  also  superficial  and  deep ;  they  terminate 
in  the  lymphatic  ganglions,  and  are  always  placed  at  the  articulations  ; 
some  nerves,  which  interlace  in  a  plexus  at  the  origin  of  the  limb  ; 
much  cellular  tissue,  which  must  be  divided  into  the  sub-cutaneous 
and  sub-aponeurotic  ;  the  first  is  more  compact,  and  retains  nearly  all 

*  This  structure  does  not  exist  in  all  animals.  Carlisle  has  demonstrated,  that  in  the  loris 
and  the  tardigrade,  the  arteries  of  the  limbs,  on  entering  there,  divide  into  numerous  ramus- 
cales,  and  again  unite  in  one  trunk.  Is  this  singular  peculiarity  of  structure  intended  to 
diminish  the  action  of  the  muscles,  by  retarding  the  course  of  the  blood  in  the  limbs?  Is 
this  also  the  cause  of  the  slow  gait  of  these  animals  ? 

\  This  opinion  is  entirely  opposite  to  that  of  authors  generally,  but  it  is  founded  on  the 
results  of  a  great  number  of  comparative  dissections  and  injections  of  the  two  venous  layers 
of  the  limbs.  A  good  idea  of  this  may  be  gained  by  inspecting  Plate  seventh,  where  in  Fi- 
gure first  the  superficial  veins  have  been  figured  as  distended  by  the  injection,  as  are  also 
the  deep-seated,  Figure  second.  The  nodosities,  which  mark  on  the  outside  the  valves,  are 
much  more  common  in  the  latter.  It  is  sufficient  to  mention  this  fact,  without  assigning  a 
reason  ;  as,  however,  authors  have  attempted,  theoretically,  to  demonstrate  the  necessity  that 
the  valves  should  predominate  in  the  superficial  veins  of  the  limbs,  it  becomes  at  least  curious 
to  examine  this.  Numerous  veins  were  necessary  in  the  deep  valves,  because  their  parietes 
are  feeble,  and  because  being  pressed  upon  by  the  muscles,  in  the  interstices  of  which  they 
are  situated,  their  parietes  must  overcome,  in  the  circulation,  considerable  friction  ;  and  per- 
haps, also,  because,  being  near  the  arteries,  in  which  the  blood  circulates  from  above  down- 
ward, a  shock  is  necessarily  impressed  upon  them  in  this  direction.  The  case  is  the 
reverse  with  the  superficial  veins,  and  they  have  less  need  of  these  moveable  valves,  which 
facilitate  the  course  of  the  venous  blood,  by  breaking  the  columns  which  it  forms,  and  con- 
sequently, by  allowing  a  less  weight  to  press  on  the  lower  part  of  the  tube  of  the  veins,  and 
on  their  capillary  system. 


248  TOPOGRAPHICAL  ANATOMY. 

the  cellular  tissue ;  the  second  is  more  loose  and  lamellar,  and  contains 
but  little  of  cellular  tissue,  which  is  always  seen  in  certain  places ; 
finally,  the  skin,  which  is  more  or  less  hairy,  and  more  dense  on  the 
back  of  the  limb  than  on  the  opposite  face. 

2.  Relations.  These  different  elements  are  arranged  in  every  part 
in  the  following  order  :  the  skin,  a  cellulo-fatty  layer,  which  contains 
all  the  cutaneous  vessels  and  nerves,  particularly  the  veins  and  the 
large  lymphatics  ;  the  inextensible  enveloping  aponeurosis  ;  the  super- 
ficial and  the  deep  muscles,  most  of  which  are  surrounded  by  a  special 
sheath,  and  contain  between  them  the  large  vascular  and  nervous 
trunks  ;  finally,  the  bones,  which  occupy  the  deep  parts. 

Development.  In  the  very  young  fetus,  the  limbs  do  not  appear  in 
the  ovoid  mass  which  represents  it;  but  they  soon  vegetate,  like  small 
excrescences.  They  are  the  rudiments  of  the  limbs  ;  their  form  is  at 
first  very  indistinct ;  but  as  they,  increase  in  length,  it  becomes  very 
apparent.  The  first  distinct  part  of  the  limbs  is  not,  as  we  might 
suppose,  their  base  or  upper  part,  but  the  extremity,  the  hand  or .  the 
foot ;  after  this,  we  perceive  the  section  next  above  it,  and  so  on,  suc- 
cessively; so  that  the  part  of  the  limb  attached  to  the  trunk,  appears 
last :  it  is  evident,  that  we  allude  here  to  the  development  of  the  ex- 
ternal form  of  the  limbs,  for  we  should  arrive  at  an  opposite  conclusion 
if  we  examine  the  development  of  the  limbs  in  respect  to  structure. 
The  five  segments  which  terminate  each  limb  in  man,  are  not  at  first 
distinct ;  they  are  blended  or  united  by  a  membrane,  as  is  seen  at  the 
adult  age  in  certain  animals,  particularly  in  web-footed  birds. 

Varieties.,  During  the  early  periods  of  life,  the  limbs  are  remarka- 
ble for  their  rounded  form,  which  depends  on  the  sub-cutaneous  fat, 
and  for  their  enlargements  at  the  articulations  ;  in  the  adult,  the  mus- 
cular prominences  are  visible,  as  the  secretion  of  fat  is  diminished  ;  in 
the  old  man,  the  fat  disappears  in  great  part  in  the  limbs  ;  they  remain 
thin,  and  the  prominences  of  the  bones  are  visible. 

In  the  female,  the  infantile  state  continues,  the  sub-cutaneous  fat 
enlarges  the  limbs,  at  the  same  time  that  it  contributes  to  their  grace, 
by  concealing  the  prominences  of  the  bones  and  muscles.  When  the 
development  is  not  regular,  the  limbs  may  be  deficient  or  entirely  ru- 
dimentary, as  has  been  mentioned  when  speaking  of  the  development, 
which  may  be  arrested  at  variable  periods.. 

Uses.  Nature  has  admirably  formed  the  limbs  for  a  double  purpose, 
solidity  and  mobility,  which,  however,  are  generally  in  an  inverse 
ratio  with  each  other ;  sometimes  one,  sometimes  the  other,  predomi- 
nates. The  greatest  mobility  is  found  at  the  union  of  the  first  two 
sections ;  the  loose  section,  on  the  contrary,  is  remarkable  for  its 
solidity. 


THORACIC  LIMBS.  249 

Pathological  and  operative  deductions.  A  great  number  of  general 
consequences,  which  are  very  useful,  may  be  deduced  from  the  pre- 
ceding facts.  In  fact,  did  not  the  two  muscular  layers  of  the  limbs 
lead  Petite  and  Cheselden  to  propose  cutting  the  muscles  at  two  peri- 
ods, in  circular  amputations,  in  order  to  obtain  a  stump  representing 
a  hollow  cone  ?  Is  it  not  the  inextensibility  of  the  enveloping  aponeu- 
rosis,  which  renders  deep  inflammations  of  the  limb  so  serious,  while 
the  superficial  are  so  slight  1  Do  not  these  same  anatomical  facts  lead 
us  to  make  large  incisions,  in  order  to  remove  the  strangulation  pas- 
sively exercised  by  this  inextensible  layer  on  the  deep  parts  ?  Is  it 
not  because  all  the  arteries  of  a  limb  come  from  a  single  trunk,  that 
this  is  compressed  in  operations,  that  it  is  tied  to  arrest  a  hemorrhage 
from  the  part  below  it,  or  to  check  the  progress  of  aneurism  ?  And, 
finally,  after  this  ligature  is  applied,  does  not  gangrene  sometimes  su- 
pervene below  the  ligature,  although  much  more  frequently  the  col- 
lateral communications  with  the  arteries  of  the  trunk  are  sufficient  to 
maintain  the  vitality  of  the  parts?  Is  not  a  similar  arrangement  in 
the  venous  system  of  the  limbs  sufficient  to  show  that  the  ligature,  the 
compression  or  the  obliteration  of  a  vein  of  the  limbs,  by  clots,  may 
cause  infiltration  and  abscesses?  Finally,  is  it  not  on  account  of  the 
too  great  natural  mobility  of  certain  points  of  the  limbs,  that  luxations 
supervene  there  so  frequently,  and  fractures  more  rarely ;  the  bones,  in 
fact,  yielding  before  the  causes  of  fracture,  while,  where  the  parts  are 
more  solid  arid  less  moveable,  we  observe  the  opposite  phenomenon  ? 


SECTION     I. 

OF     THE     THORACIC     LIMETS. 

These  limbs  are  the  articulated  prolongations  of  the  thoracic  part 
of  the  trunk.  They  are  the  anterior  limbs  of  quadrupeds,  the  wings 
of  the  cheiroptera  and  of  birds,  the  pectoral  fins  of  fishes. 

In  a  well-formed  male,  the  thoracic  limb  is  so  long,  that,  when 
extended  on  the  sides  of  the  trunk,  it  descends  to  the  middle  of  the  thigh. 
This  limb  is  singularly  elongated,  by  the  arrangement  of  the  hand, 
which,  being  articulated  with  one  of  its  extremities  by  the  fore-arm, 
adds  its  own  length  to  that  of  the  limb.  In  animals,  the  proportional 
extent  of  this  limb  is  very  much  increased. 

32 


250  TOPOGRAPHICAL  ANATOMY. 

In  order  to  study  the  thoracic  limb,  we  consider  it  as  hanging  on  the 
side  of  the  trunk,  the  palm  of  the  hand  looking  forward.  In  this 
position,  we  distinguish,  an  anterior  palmar  face,  which  is  slightly 
concave  in  the  centre ;  a  posterior  dorsal  face,  convex  in  the  same 
point ;  two  edges,  one  of  which  is  radial,  and  is  remarkable  for  three 
eminences  arranged  on  the  same  line ;  the  acromion  process,  the  epi- 
condyle  and  the  styloid  apophysis  of  the  radius,  which  arrangement 
must  be  constantly  kept  in  mind  in  reducing  fractures  ;  the  other,  the 
cubital,  which  also  presents  three  eminences,  the  head  of  the  humerus, 
the  epitrochlea,  and  the  styloid  process  of  the  ulna,  which  eminences 
are  not  arranged  like  the  preceding ;.  in  fact,  the.  central  is  more  in- 
ternal than  the  other  two  ;  the  base  of  this  limb  rests  on  the  upper  side 
of  the  thorax ;  its  summit  is  loose,  and  is  represented  by  the  extremity 
of  the  fingers. 

Development.  The  thoracic  limb  appears  earlier  than  the  abdomi- 
nal limb ;  its  development  is  connected  with  that  of  the  lower  part  of 
the  neck,  from  which  its  nerves  proceed ;  it  is  formed  with  the  neck, 
in  the  variety  of  acephalia,  termed  by  Beclard,  atrachelo-cephalia  ;  it 
is  absent,  on  the  contrary,  although  the  thorax  exists,  in  the  other 
variety,  termed  abrachio-cephalia. 

Uses.  Every  thing  in  the  thoracic  limb  is  calculated  for  mobility ; 
the  levers  generally  employed  are  those  of  the  third  class  ;.  these  levers 
are  not  very  solid,  but  extremely  moveable,  and  find  points  of  support 
in  the  loose  articulations,  the  cavities  of  which  are  superficial ;  .the 
powers  which  move  these  levers  are  inserted  in  them  very  obliquely ; 
the  section  by  which  this  limb  rests  on  the  trunk  is  itself  very  movea- 
ble, and  its  attachment  to  this  part  is  not  very  firm.  These  circum- 
stances favor  the  mobility,  and  hence  dislocations  of  these  limbs  are 
more  common  than  fractures. 

The  four  divisions  of  the  thoracic  limb  are,  the  shoulder,  the  arm, 
the  fore-arm,  and  the  hand,  which  we  shall  examine  successively. 


CLAVICULAR  REGION.  251 


CHAPTER      I . 


OP       THE       SHOULDER. 

The  first  part  of  the  thoracic  limb,  the  shoulder,  is  the  base  by 
which  this  limb  rests  on  the  trunk;  its  height  and  breadth  are  mea- 
sured by  that  of  the  two  regions  which  form  it,  and  we  shall  conse- 
quently speak  of  it  hereafter.  The  shoulder  of  man  is  moveable  on 
the  trunk,  and  it  contributes  singularly  to  the  mobility  of  the  whole 
limb;  it  may  be  raised,  depressed,  carried  forward,  backward,  and 
may  be  rotated. 

Notwithstanding  the  early  development  of  the  bones  of  the  shoulder, 
this  part  of  the  thoracic  limb  is  the  last  to  appear  in  the  fetus :  this 
would  seem  contradictory  to  what  is  generally  admitted  in  regard  to 
its  bones,  if  we  did  not  premise,  that  in  describing  the  evolutions  of 
the  limbs,  we  only  referred  to  the  appearance  of  their  external  form 
and  their  separation  from  the  trunk. 

The  skeleton  of  the  shoulder  is  formed  by  two  bones,  the  scapula 
and  the  clavicle,  which  are  firmly  united,  and  represent  a  bent  lever, 
on  the  two  branches  of  which  different  organs  rest,  which  thus  form 
two  regions,  the  clavicular  and  the  scapular.  Farther,  this  portion  of 
the  thoracic  limb,  by  uniting  with  the  arm  and  the  trunk,  contributes 
to  form  two  other  regions,  the  shoulder  and  the  axilla. 


1  .      CLAVICULAR       RE  'G   ION. 

Tliis  region  is  very  simple,  and  composed  of  the  organs  which  are 
situated  around  the  clavicle  ;  it  forms  the  upper  and  anterior  portion 
of  the  shoulder.  Its  edges  are  well  marked  externally,  they  show  the 
form  of  the  clavicle  ;  on  the  inside,  also,  this  region  projects  forward, 
while  externally  it  seems  to  retreat.  Its  length  varies  much,  and  is 
measured  by  that  of  the  clavicle.  In  the  female  it  is  larger,  on  account 
of  the  disappearance  of  the  curve  of  this  bone ;  farther,  its  boundaries 
are  easily  perceived. 

Structure.  —  I.  Elements.  The  structure  of  this  small  region  is 
not  very  complex.  The  clavicle  forms  its  point  of  support,  and  its 
skeleton  ;  the  sterno-clavicular  articulation  has  been  examined  in  the 
sternal  region ;  we  will  here  add,  that  the  clavicle  is  also  united  on  the 
inside  to  the  first  rib,  sometimes  by  diarthrosis,  most  frequently  by  the 


252  TOPOGRAPHICAL  ANATOMY. 

costo-clavicular  ligament,  which  is  deficient  in  the  former  case.  On 
the  outside,  this  bone  is  connected  firmly  with  the  scapula  in  two 
points,  first,  by  its  extremity,  to  the  acromion  process,  second,  by  its 
lower  face,  to  the  coracoid  process,  by  the  cofaco-clavicular  ligaments  ; 
this  double  scapulo-clavicular  articulation  is  extremely  important,  in 
respect  to  certain  fractures  of  the  clavicle.  The  muscles  attached  to 
this  point  are  the  subclavius,  the  platysma,  the  insertions  of  the  del- 
toides,  the  trapezius,  and  the  sterno-mastoideus  muscles ;  we  find  there 
a  small  aponeurosis,  remarkable  for  its  strength  on  the  outside ;  this  is 
the  clavicular  aponeurosis,  the  fascia  clavicularis ;  it  is  attached  on 
the  anterior  edge  of  the  clavicle,  and  on  the  coracoid  process,  by  a 
fasciculus,  which  we  have  long  described  as  a  third  coraco-clavicular 
ligament ;  it  is  extended  into  the  anterior  wall  of  the  hollow  of  the 
axilla,  where  it  is  situated  on  the  axillary  vessels  and  nerves,  and  it  is 
attached  to  the  upper  edge  of  the  pectoralis  minor  muscle.  The  ves- 
sels and  nerves  of  this  region  are  of  but  little  importance  ;  we,  however, 
do  not  allude  to  the  brachial  vessels  and  nerves,  which  are  situated 
below  it ;  the  supra-clavicular  filaments  of  the  cervical  plexus,  only, 
pass  through  the  clavicular  region.  The  sub-cutaneous  cellular  tissue 
is  small  in  quantity,  is  dense,  and  not  very  fatty ;  under  the  platysma, 
it  has  an  opposite  arrangement.  The  skin  presents  nothing  peculiar. 

2.  Relations.  The  clavicle  forms  in  this  region,  to  which  it  gives 
its  name,  a  central  layer,  receiving  in  its  outer  third  posteriorly,  the 
insertion  of  the  trapezius  muscle,  and  anteriorly,  that  of  the  deltoides  ; 
the  sterno-mastoideus  muscle  is  inserted  posteriorly,  and  the  pectoralis 
major  muscle  anteriorly,  in  its  inner  third,  while  in  the  centre,  its  two 
edges  are  loose.  The  skin  is  separated  from  it  by  a  slightly  fatty  and 
dense  cellular  tissue,  by  the  platysma  muscle,  on  which  the  supra- 
clavicular  nervous  filaments  are  situated  on  the  inside,  and  finally,  by 
a  looser  cellulo-fatty  layer.  The  subclavius  muscle  is  covered  ante- 
riorly by  the  clavicular  aponeurosis,  which  forms  for  it  a  solid  semi- 
sheath,  separates  it  below  from  the  upper  opening  of  the  hollow  of  the 
axilla,  and  from  the  vessels  and  nerves  which  pass  through  it ;  on  the 
inside,  the  costo-clavicular  ligament,  alone,  exists  between  it  and  the 
first  rib ;  on  the  outside,  it  is  united  to  the  coracoid  process,  and  to  the 
coraco-acromial  ligament,  by  the  coraco-clavicular  ligaments,  and  by 
a  cellulo-fatty  body. 

Development.  This  part  of  the  shoulder  is  short,  and  but  slightly 
curved  in  the  child ;  at  the  period  of  puberty,  it  acquires  the  develop- 
ment upon  which  our  description  is  founded. 

Uses.  When  the  whole  shoulder  is  moved,  this  region,  by  a  singu- 
larly variable  position,  also  causes  the  axillary  arid  'supra-clavicular 
regions  to  vary. 


SCAPULAR  REGION.  253 

Pathological  and  operative  deductions.     Superficial  wounds  of  this 
region  are  very  slight ;  the  small  operations  sometimes  performed  upon 
it,  produce  pains,  which  extend  to  the  neck  and  the  shoulder,  by  means 
of  the  supra-clavicular  nervous  filaments.     Central  fractures  of  the 
clavicle  may  be  very  serious,  when  they  are  produced  directly  by  a 
force  which  acts  from  above  downward ;  in  fact,  the  fragments  may 
be  pushed  towards  the  axillary  vessels  and  nerves ;  fractures  of  the 
clavicle  are  produced,  most  generally,  by  a  counterblow,  and  then 
they  are  not  followed  by  these  symptoms,  but  only  with  displacement ; 
in  fact,  their  external  fragment  is  drawn  downward  by  the  weight 
of  the  whole  limb,  which  cannot  support  the  action  of  the  trapezius 
muscle ;  on  the  other  hand,  the  internal  fragment  is  kept  motionless, 
by  the  contraction  of  the  sterno-mastoideus  muscle,  and  particularly 
because  it  is  acted  upon  by  no  force  ;  from  these  different  circumstan- 
ces, there  is  a  displacement  in  the  thickness,  and  also  an  overlapping, 
produced  by  the  traction  of  the  shoulder  toward  the  trunk,  from  the 
contraction  of  the  pectoralis  major  and  latissinms  dorsi  muscles.    If  the 
clavicle  be  fractured  on  the  outside,  between  its  acromial  and  coracoid 
articulations,  the  fragments  cannot  be  displaced,  because  they  are  both 
united  to  parts  of  the  scapula  which  have  invariable  relations,  and  also 
because  the  trapezius  muscle  is  inserted  backward  and  upward,  the 
deltoides  muscle  forward  and  downward,  in  both  of  these  parts.     Ca- 
ries and  necrosis  of  the  clavicle  are  common ;  its  superficial  position 
exposes  it  to.  syphylitic  exostoses.     The  whole  clavicular  region  may 
be  depressed  toward  the  axilla,  or  elevated  toward  the  neck,  by  tumors 
developed  in  the  neck  or  in  the  axilla. 


2.     SCAPULAR     REGION. 

This  region  is  composed  of  all  the  organs  which  rest  on  the  two 
faces  of  the  scapula,  and  is  larger  and  more  complex  than  the  prece- 
ding ;  it  forms  the  posterior  part  of  the  shoulder,  and  rests  on  the  tho- 
rax, which  it  enlarges  upward  and  backward.  Its  form  is  that  of  a 
triangle,  the  base  of  which  is  superior ;  its  height  ekceeds  its  breadth  ; 
in  a  state  of  rest  it  rises  to  the  first  true  rib,  and  never  extends  below 
the  sixth  ;  its  limits  can  be  seen,  or  are  easily  felt. 

The  scapular  region  presents  two  faces,  a  posterior,  which  is  cuta- 
neous, and  an  anterior  or  axillary.  The  first  is  covered  with  hairs  in 
adult  males,  it  is  convex,  and  shows,  in  lean  individuals,  the  oblique 
prominence  of  the  spine  of  the  scapula;  the  second  is  concealed  deeply 
in  the  hollow  of  the  axilla,  to  the  parietes  of  which  it  contributes ;  it 
is  nearly  plane,  and  cannot,  for  this  reason,  rest,  except  by  one  point, 


254  TOPOGRAPHICAL  ANATOMY. 

its  posterior  edge,  on  the  convex  face  of  the  costal  region ;  this  face, 
also,  of  the  region,  forms  with  the  costal  region  a  sinus,  open  anteri- 
orly, which  constitutes  the  hollow  of  the  axilla,  as  we  shall  soon  see. 
Structure..  —  1.  Elements.  The  .skeleton  of  this  portion  of  the 
shoulder  is  represented  by  the  scapula,  and  presents,  posteriorly,  the 
supra-  and  infra-spinal  fossae,  separated  by  the  root  of  the  acromion 
process,  and  anteriorly,  the  sub-scapular  fossa ;  the  adjacent  part  of  the 
shoulder  also  belongs  to  it.  The  supra-  and  infra-spinatus,  and  the 
siib-scapularis  muscles,  are  nearly  the  only  intrinsic  muscles.  .  We  find 
there  only  a  portion  of.  the  trapezius,  the  deltoides,  the  latissimus  dorsi, 
and  of  the  teres  minor  and  .major  muscles :  the  rhomboideus,  the  leva- 
tor  anguli  scapulas,  the  scapulo-hyoideus,  and  the  serratus  major  anti- 
cus  muscle,  go  only  to  the  limits  of  the  region.  We  do  not  mention 
here  those  muscles  which  leave  the  scapula,  and  only  surround  the 
shoulder.  The  scapular  region  is  strengthened  by  three  aponeuroses, 
which  keep  the  sub-scapularis,.the  supra-spinatus,  and  the  infra-spi- 
natus muscles  constantly  in  contact  with  the  bone;  those  of  the  first 
two  muscles  are  very  simple,  and  are  attached  around  the  .sub-scapular 
and  supra-spinal  fossas :  the  last,  also,  is  attached  on  the  limits  of  .the 
fossa  to  which  it  belongs,  but  it  is  also  united  to  the  trapezius  and 
deltoides  muscles,  and  extends  under  their  two  faces:  it  sends  septa 
between  the  infra-spinatus  and.the  two  teres  muscles,  and  then  between 
these  two  latter ;  these  septa  serve  for  their  insertion,  and. are  attached 
to  the  crests  of  the  scapula.  These  three  aponeuroses  are  extended 
toward  the  shoulder,  and  are  there  expanded.  The  scapular  arteries 
come  from  the  subclavian  and  axillary  ;  from  the  first  come  the  pos- 
terior and  superior  scapular,  and  the  common  scapular  and  posterior 
circumflex  from  the  second  ;  they  arise  very  low.  These  vessels  anas- 
tomose extensively  in  the  scapular ;  region,  and  establish  a  very  im- 
portant collateral  circulation  between  the  subclavian  arid  the  end  of  the 
axillary  artery ;  one  anastomosis  is  situated  near  the  lower  angle  of  the 
scapula,  it  is  formed  by  a  branch  of  the  common  scapular  artery, 
which  follows  the  anterior  edge  of  the  region,  and  by  the  end  of  the 
posterior  scapular  artery,  which  extends  along  its  spinal  edge  :  another, 
the  dorsal,  is  formed  by  the.  second,  branch  of  the  common  .scapular 
artery,  and  by  the  end  of  the  superior  scapular.  The  veins  attend 
the  arteries,  as  do  also  the  deep  lymphatic  vessels,  which  go  with  the 
superficial  into  the  axillary  and  cervical  ganglions ;  some  of  the  latter 
turn  on  the  posterior  edge  of  the  axilla,  and  others  re-ascend  on  the 
trapezius;  the  cellular  tissue  is  dense  only  under  the  skin,  it  contains 
very  little  fat,  and  we  find  but  little  of  it  deeply,  except  between  the 
trapezius  and  the  supra-spinatus  muscles ;  the  skin  is  remarkable  sim- 


SCAPULAR  REGION.  255. 

ply  for  its  firmness,  its  numerous  follicles,  and  the  hairs  which  cover 
it  in  very  hairy  men. 

2.  Relations.     The  relations  of.  the  scapular  organs  must  be  con- 
sidered at  the  supra-spinal  and  infra-spinal  fossae.     In  the  first  space, 
which  is  very  small,  we  find  successively ;  the  skin,  a  dense  cellulo- fatty 
layer,  the  trapezius,  a  cellulo-adipose  body,  which  is  large,  particularly 
on  the  outside,  doubtless  to  shield  in  this  point  the  posterior  edges  of  the 
clavicle  and  of  the  apromion  process,  in  which  body  we  see  a  very, 
considerable  twig  of  the  posterior  scapular  artery ;  more  deeply,  come 
the  supra-spinal  fascia,  the  supra-spinatus  muscle,  and  between  it  and 
the  bone,  on  the  outside;  the  supra-scapular  vessels  and  nerve,  the  last 
passing  by  itself  into  the  coracoid  foramen,  on  which  the  scapulo- 
hyoideus  muscle  is  inserted ;  finally,  below  the  bone,  the  sub-scapularis 
muscle,  and  its  aponeurosis.     At  the  infra-spinal  fossa,  we  demon- 
strate successively  by  dissection  ;  the  skin,  the  cellulo-fatty  layer  al- 
ready mentioned  ;  in  which  layer  we  find  only  some  cutaneous  twigs 
of  the  common  scapular  artery,  and  the  circumflex  vessels  and  nerves ; 
a  third  layer,  formed  first  above  by. the  deltoides,  covered  with  a  thin 
aponeurotic  layer,  which  is  continuous  with  the  infra-spinal  aponeuro- 
sis, and  by  the  triangular  tendon  of  the  trapezius,  which  adheres  to 
this  same  aponeurosis;  second,  below,  by  the  latissimus  dorsi ;  third, 
in  the  centre,  by  the  infra-spinatus,  the  teres  major  and.minor,  which 
are  covered  with  the  infra-spinal  aponeurosis.     Although  these  last 
organs  form  here,  a  superficial  plane- with  the  deltoides  muscle,  the 
trapezius  and  the  latissimus  dorsi  constitute  also  a  subjacent  layer: 
finally,  below  them,  and  on  the  outside,  we  find  the  large  anastomosis 
of  the  common  and  superior  scapular  arteries,  and  the  skeleton,  on  the 
inside  of  vyhich  appear  also,  the  sub-scapularis  muscle,  and  its  aponeu- 
rosis;    The  posterior  scapular  artery,  the  inferior  branch  of  the  com- 
mon scapular,  and  the  great  anastomosis,  which  unites  them  near  the 
inferior  scapular  angle,  are  situated,  on  the  limits  of  the  region. 

Varieties.  In  some  individuals  the  posterior  edge  of  the  scapular 
region  is  elevated  posteriorly,  a  very  common  variety,  most  generally 
produced  by  the  transverse  contraction  and  lateral  roundness  of  the 
thorax,  but  which  may  also  be  caused  by  the  shortness  of  the  clavicle. 
This  deviation  of  formation  gives  to  the  chest  a  peculiar  appearance. 
In  females,  the  transverse  diameter  of  the  chest  is  slight,  but  the  great 
length  of  the  clavicle,  extending  the  scapular  region  outward,  allows 
the  posterior  edge  of  .the'  latter  to  rest  as  in  the  male.  This  region  is 
extremely  moveable  ;  besides  the  general  motions  of  the  shoulder  in 
which  it  participates,  its  muscles  rotate  it  around  an  imaginary  axis, 
which  would  pass  through  its  centre ;  in  this  motion,  the  inferior  an- 
gle is  carried  sometimes  forward  and  sometimes  backward. 


• 

256  TOPOGRAPHICAL    ANATOMY. 

Pathological  and  operative  deductions.  The  scapular  region  is 
not  very  interesting  in  a  pathological  point  of  view,  although  very 
important,  first,  in  respect  to  its  uses  as  the  wall  of  the  axilla  ;  second, 
on  account  of  the  anastomoses  of  its  arteries,  by  which  we  are  enabled 
to  tie  the  axillary  and  subclavian  arteries,  without  any  interruption  in 
the  circulation,  from  the  scaleni  muscles  to  the  base  of  the  axilla ;  it  is 
rarely  fractured  on  account  of  its  mobility,  and  of  the  muscular  mass, 
a  sort  of  elastic  cushion,  which  protects  its  skeleton  on  the  external 
surface.  Its  spine  is  the  only  superficial  part.  The  chest  is  often  ex- 
amined by  percussion,  above  this  region  ;  we  must  then  expect  to  obtain 
generally  a  more  obscure  sound.  The  immediate  relations  of  the 
supra-spinal  fossa  with  the  summit  of  the  lung,  enables  us  to  perceive 
there  pectoriloquy,  in  persons  affected  with  phthisis.  Tonnele  has 
shown  us  a  scapula  which  presented  an  opening,  through  which  a 
large  pouch,  filled  with  acephalocyst  hydatids,  extended  at  the 
same  time  upon  the  axillary  and  dorsal  faces  of  the  scapular  region, 
raising  on  one  side  the  sub-scapularis  muscle,  on  the  other,  the  infra- 
spinatus  muscle. 


3.       SCAPULO-HUMERAL      REGION. 

The  shoulder,  by  uniting  with  the  arm,  forms  a  blunt  prominence, 
which  has  for  the  centre  the  scapulo-humeral  articulation  ;  it  is  the 
top  of  the  shoulder,  or  the  scapulo-humeral  region. 

On  the  inside,  it  contributes  to  form  the  axilla,  it  descends  downward, 
below  the  pectoralis  major  and  the  latissimus  dorsi  muscles,  which 
unite  it  to  the  trunk ;  above,  its  limits  are  less  exactly  defined,  and  are 
formed  by  the  most  external  portions  of  the  clavicular  and  scapular 
regions. 

The  shoulder  is  covered  externally  with  hair  in  hairy  men.  Its  form 
is  rounded,  when  the  arm  is  depressed.  By  pressing  upon  it,  we  can 
distinguish,  above,  the  acromion  process  and  the  clavicle ;  on  the  in- 
side deeply,  the  coracoid  process  ;  between  these  and  the  first  two,  a 
triangular  depression,  which  corresponds  to  the  coraco-acromial  liga- 
ment and  to  the  upper  part  of  the  articulation,  which  in  this  place  only 
can  be  injured  from  above  downward  ;  finally,  below,  are  two  sub-cu- 
taneous prominences,  an  anterior  and  a  posterior,  which  unite  the 
shoulder  to  the  trunk  and  blend  them  ;  these  are  the  prominences  of 
the  pectoralis  major,  and  of  the  latissimus  dorsi,  and  of  the  teres  major 
muscles  united. 

Structure.  —  1.  Elements.  The  scapulo-humeral  articulation  forms 
the  centre  of  this  region.  We  shall  merely  mention  the  length  of  its 


SCAPULO-HUMERAL  REGION*  257 

fibrous  capsule,  which  allows  a  greater  separation  between  the  surfaces 
which  it  keeps  in  place,  its  weakness  at  the  lower  part,  while  posteri- 
orly, above  and  below,  it  is  strengthened  or  formed  entirely  by  the 
flat  and  very  strong  tendons  of  several  muscles.  The  extremity  of  the 
humerus  found  in  this  region,  is  composed  of  the  head  of  this  bone,  of 
the  very  short  anatomical  neck,  which  supports  it  and  separates  it  from 
the  tuberosities,  and  also  of  the  surgical  neck,  which  part  comprises 
the  space  between  the  tuberosities  and  the  place  where  the  pectoralis 
major  and  latissimus  dorsi  muscles  are  inserted.  This  articulation  is 
formed  by  the  glenoid  cavity  and  the  neck  of  the  scapula ;  it  is  pro- 
tected by  an  osseo-fibrous  arch,  formed  on  the  outside  by  the  acromion 
process,  on  the  inside  by  the  coracoid  process,  in  the  centre,  by  the 
coraco-acromial  ligament,  which  is  partly  covered  by  the  acromial  ex- 
tremity of  the  clavicle,  and  is  partially  exposed  to  injury  in  a  triangular 
space  already  mentioned.  The  muscles  of  the  shoulder  are  numerous, 
but  none  belong  exclusively  to  it ;  we  find  there  the  tendinous  extre- 
mities of  the  supra-spinatus,  infra-spinatus,  teres  minor,  and  sub-sca- 
pularis  muscles,  all  of  which  are  deep,  and  contribute  directly  to  form 
the  articulation  ;  then,  the  upper  extremity  of  the  deltoides,  of  the  bi- 
ceps, of  the  coraco-brachialis,  of  the  long  portion  of  the  triceps,  of  the 
pectoralis  major,  of  the  latissimus  dorsi,  of  the  teres  major,  and  some 
fibres  of  the  platysma ;  the  long  portion  of  the  biceps  passes  through 
the  articulation,  the  triceps  is  inserted  directly  below  it,  behind  the 
lower  part  of  its  vertical  diameter ;  the  scapular  aponeuroses  are  all 
extended,  and  terminate  in  this  point,  where  the  brachial  aponeurosis 
commences  by  a  thin  layer. 

The  arteries  come  from  the  acromial,  the  circumflex,  and  the  com- 
mon scapular  artery.  The  veins  attend  the  arteries,  except  the  cephalic, 
which  proceeds  on  the  anterior  limits  of  the  region.  Superficial  lym- 
phatic vessels  go  partly  to  the  axillary  and  partly  to  the  cervical  gang- 
lions ;  the  deep  proceed  to  the  first  exclusively.  The  nerves  of  the 
shoulder  are  given  off  superficially  by  the  supra-acromial  and  supra- 
clavicular  filaments  of  the  cervical  plexus  ;  the  deep  nerves  come  from 
the  circumflex  nerve. 

Generally,  the  cellular  tissue  of  the  shoulder  is  not  very  abundant, 
and  very  loose  ;  this  is  particularly  remarkable  under  the  muscles, 
where  it  frequently  forms  a  mucous  bursa,  particularly  between  the 
deltoides  muscle,  the  acromion  process,  and  the  articular  capsule.  Most 
of  the  fat  is  sub-cutaneous. 

2.  Relations.  The  relations  of  this  region  are  very  important,  and 
must  be  examined  superiorly,  posteriorly,  anteriorly,  and  also  inferiorly. 

In  the  first  point,  which  corresponds  to  the  deltoides  muscle,  we 
find,  successively ;  the  skin,  an  abundant  cellulo-adipose  layer,  into 

33 


253  TOPOGRAPHICAL  ANATOMY^* 

which  some  fibres  of  the  platysma  and  the  supra-acromial  filaments  of 
the  superficial  cervical  plexus  extend ;  a  thin  aponeurotic  layer  is  con- 
tinued between  the  fasciculi  of  the  deltoides,  and  is  connected  anteri- 
orly with  the  sub-cutaneous  tissue  of  the  thorax,  posteriorly  with  the 
infra-spinal  aponeurosis,  inferiorly  with  the  brachial  aponeurosis ;  the 
deltoides  muscle  is  separated  anteriorly  from  the  pectoralis  major  by  a 
groove,  where  we  see  the  cephalic  vein  and  the  vertical  branch  of  the 
acromial  artery.  The  deltoides  muscle  being  turned  back,  we  see, 
superiorly,  the  transverse  branch  of  the  acromial  artery,  passing  on 
the  coraco-acrornial  ligament  and  on  the  coraco-clavicular  triangle, 
which  has  been  rendered  so  important  by  Lisfranc's  mode  of  disarti- 
culating the  arm,  and  farther  back,  the  fibrous  capsule,  the  tendons  of 
the  supra-spinatus,  infra-spinatus,  and  teres  minor  muscles  which 
strengthen  it,  the  sheath  of  the  long  portion  of  the  biceps,  under  which 
the  small  anterior  circumflex  artery  passes  from  within  outward ; 
finally,  still  more  inferiorly,  the  posterior  circumflex  vessels  and 
nerves,  which  form  a  plexus  around  the  surgical  neck  of  the  humerus  ; 
all  these  parts  are  separated  from  the  deltoides  by  a  very  loose  cellular 
tissue,  which  is  lamellar,  and  often  above  by  a  mucous  bursa,  which 
glides  under  the  acromial  arch. . 

This  region  is  continuous  anteriorly  with  the  anterior  wall  of  the 
axilla,  and  we  find  there  successively  ;  the  skin,  a  cellule-fatty  layer, 
some  fibres  of  the  platysma,  and  some  supra  ^clavicular  nerves  of  the 
cervical  plexus,  the  terminating  extremity  of  the  pectoralis  major  mus- 
cle, which  is  separated,  as  has' been  said,  from  the  deltoides,  the  short 
portion  of  the  biceps,  the  coraco-brachialis  muscle,  and  under  them, 
above,  the  tendon  of  the  sub-scapularis  muscle,  below,  the  anterior  cir- 
cumflex vessels. 

Inferiorly,  the  shoulder  is  continuous  with  the  posterior  "wall  of  the 
axilla,  and  consequently  with  the  trunk  ;  in  this  direction,  it  is  formed 
from  behind  forward  by  the  skin,  a  thin  aponeurosis,  the  posterior 
edge  .of  the  deltoides,  the  long  portion  of  the  triceps,  the  teres  major, 
and  the  latissimus  dorsi  muscles  united,  the  first  being  situated  poste- 
riorly, the  second  anteriorly;  finally,  between  these  three  muscles  and 
the  surgical  neck  of  the  humerus,  the  posterior  circumflex  vessels  and 
nerves,  and  the  weakest  portion  of  the  fibrous  capsule. 

Development.  In  youth,  the  osseous  parts  which  protect  the  scapu- 
lo-humeral  articulation  are  less  prominent,  and  are.  cartilaginous. 

Varieties.  This  region  often  changes  its  form,  during  the  different 
movements  in  its  articulation.  In  the  male,  the-  scapulo-humeral  re- 
gions are  thrown  directly  outward  ;  they  are  carried  a  little  posteriorly 
in  the  female.  Boyer  mentions  a  posterior  slope  of  the  glenoid  cavity, 


SCAPULO-HUMERAL  REGION.  259 

which  facilitates  a  dislocation  in  this  direction,  which  is  otherwise 
impossible. 

Pathological  and  operative  deductions.     When  fractures  supervene 
in  this  region,  they  affect  particularly  the  acromion  process  or  the  cla- 
vicle, on  account  of  the  superficial  position  of  these  parts;  a  more 
violent  effort  is  necessary  to  fracture  the  coracoid  process,  which  is 
protected  by  the  deltoides  muscle  and  by  its  internal  position  ;  a  great 
degree  of  violence  is  required  to  break  the  neck  of  the  scapula ;  hence, 
these  last  fractures  are  much  more  serious.     When  they  affect  the 
humerus,  they  are  situated  sometimes  in  the  anatomical  and  .sometimes 
in  the  surgical  neck.     In  the  first  -case,  the  head  of  the  humerus  being 
deprived  of  its  nutritive  vessels,  is,  in  fact,  a  foreign  body  in  the  centre 
of  the  articulation,  and  cannot  contribute  to  the  formation  of  callus ; 
hence,  this  callus  cannot  be  formed,  unless  we  consider  as  such,  amass 
of  bone  which  is  sometimes  annexed  to  the  inferior  fragment,  and 
which  surrounds  the  superior.     The  head  of  the  humerus,  subjected 
to  the  friction  of  the  irregular  summit  of  the  lower  fragment,  is  most 
commonly  absorbed,  and  soon  reduced  to  its  cartilage  of  incrustation, 
which  finally  disappears  ;  it  is  curious,  that  the  pieces  of  bone  which 
are  detached,  are  removed  but  in  a  slight  degree  by  absorption.     In 
the  second  case,  when  the  surgical  neck  is  fractured,  there  is  a  re- 
markable displacement ;  the  upper  fragment  is  drawn  upward  and 
outward  by  the  supra-spinatus,  the  infra-spinatus,  and  the  teres  minor 
muscles ;  the  inferior  is  carried,  first,  inward,  by  the  pectoralis  major 
and  the  latissimus  dorsi  muscles,  and  is  then  drawn  upward,  by  the 
contraction  of  the  deltoides,  of  the  biceps,  &c.     This  latter  fracture 
unites  readily. 

Dislocations  of  the  shoulder  Cannot  take  place  upward,  on  account 
of  the  arch  which  protects  it ;  they  are  urifrequent  backward  and  in- 
ward, on  account  of  the  resistance  of  the  tendons  which  form  the 
fibrous  capsule,  and  especially  because  the  motions  of  the  articulation 
forward  and  backward  are  confined,  particularly  the  former.  Dis- 
location inward  has  been  seen,  and  then  the  head  of  the  humerus  was 
situated  under  the  tendon  of  the  sub-scapularis  muscle;  dislocation 
backward,  according  to.  Boyer,  is  supposable  only  when  the  above 
mentioned  deviation  in  the  formation  of  the  glenoid  cavity  exists ; 
dislocations  downward,  however,  are  undoubtedly  the  most  easy ; 
the  feebleness  of  the  capsule  in  this  point,  and  especially  the  quick 
and  instinctive  contraction  of  the  pectoralis  major  and  latissimus 
dorsi  muscles,  in  falling  on  the  ground,  when  the  limb  has  been 
extended  to  support  the  body,  are  the  causes  of  this  frequency. 
The  two  muscles  mentioned,  produce  this  displacement  by  a  curious 
mechanism :  being  attached  to  the  humerus  at  the  base  of  the  shoulder, 


260  TOPOGRAPHICAL   ANATOMY. 

they  are  destined,  the  opposite  part  of  their  action  being  neutralized, 
to  bring  towards  the  trunk  the  inferior  end  of  the  corresponding  ex- 
tremity, by  making  it  swing  on  the  shoulder,  which  they  then  draw 
downward :  we  can  then  conceive,  that  in  a  fall,  whenever  the  lower 
extremity  of  the  humerus  or  of  the  limb  shall  be  fixed  on  the  ground, 
the  pectoralis  major,  latissimus  dorsi,  and  teres  major  muscles,  can  no 
longer  cause  it  to  vibrate  towards  the  trunk  as  before,  but,  on  the 
contrary,  they  will  produce  this  effect  on  the  upper  part,  the  ground 
instead  of  the  shoulder  having  become  the  centre  of  rotation  ;  hence, 
also,  a  part  of  the  combined  action  of  these  two  muscles,  being  nor- 
mally to  depress  the  shoulder,  the  continuance  of  this  action  must 
cause  the  head  of  the  humerus  to  come  from  the  lower  part  of  the 
articulation.     This  head  descends,  first,  on  the  axillary  edge  of  the 
scapula,  and  presses  more  or  less  on  the  circumflex  nerve,  which  is 
situated  in  this  point ;  hence,  a  numbness  of  the  shoulder,  which  is 
changed  into  paralysis,  if  the  pressure  continues  for  a  long  time.     The 
known  distribution  of  the  compressed  nerve,  explains  how  that  the 
deltoid  muscle,  losing  its  action,  the  power  of  raising  the  arm  is  lost. 
The  rounded  head  of  the  humerus  cannot  long  remain  on  the  sharp 
edge  of  the  scapula ;  hence,  also,  it  glides  on  it,  and  goes  upward, 
being  drawn  up  in  this  direction  by  the  contraction  of  the  deltoides, 
of  the  biceps,  &c.     The  relation  of  the  long  portion  of  the  triceps 
with  the  vertical  diameter  of  the  articulation,  explains  why  the  dis- 
placed head  of  the  humerus,  being  always  situated  in  front  of  this 
muscle,  cannot  consecutively  go  backward,  while  there  is  no  obstacle 
to  prevent  it  from  gliding  into  the  hollow  of  the  axilla,  which  is  seen 
daily :  in  all  dislocations,  the  alteration  in  the  form  of  the  shoulder  is 
evident ;  it  loses  its  roundness,  the  deltoides  is  depressed  below  the 
acromion  process,  and  this  eminence  is  prominent. 

In  scapulo-humeral  hydarthrosis,  the  tumor  appears  forward  and 
upward,  and  also  downward  and  inward,  in  the  hollow  of  the  axilla  ; 
these,  in  fact,  are  the  points  around  the  shoulder  where  the  fibrous 
articular  capsule  is  the  feeblest  or  the  least  supported :  in  the  first 
point,  the  tumor  appears  in  the  space  between  the  deltoides  and  pecto^ 
ralis  major  muscles. 

The  superficial  position  of  the  articulation  upward  and  outward, 
and  also  the  few  important  parts  which  can  be  injured  in  this  point, 
explain  why  surgeons  have  selected  it  to  make  the  incisions  necessary 
for  removing  the  head  of  the  humerus,  an  operation  performed  by 
Withe,  Vigarous,  Moreau,  Roux,  &c.  In  this  point,  whatever  mode 
of  operating  may  be  selected,  we  can  interest  only  the  skin,  the  sub- 
cutaneous cellulo-fatty  tissue,  some  supra-acromial  nerves  of  the  cer- 
vical plexus,  the  supra-deltoid  aponeurosis,  the  deltoides  muscle,  and 


AXILLARY  REGION.  261 

the  circumflex  vessels  and  nerves.  These  also  are  the  parts,  of  which, 
when  the  arm  is  amputated  at  the  articulation,  according  to  Lafaye's 
method,  the  superior  flap  is  formed,  while  the  inferior  is  composed  of 
the  inferior  and  internal  layers  of  the  shoulder,  and  also  of  the  axillary 
organs.  This  latter  flap  consequently  is  that  which  demands  the  most 
care :  it  must  be  seized  immediately  by  an  aid,  who  is  thus  enabled  to 
compress  the  principal  artery  of  the  limb.  When,  on  the  contrary, 
the  wound  has  a  perpendicular  direction,  making,  as  Desault  advises, 
a  posterior  and  an  anterior  flap,  the  first  is  composed  of  the  skin,  of 
the  sub-cutaneous  cellular  tissue,  of  the  sub-spinal  aponeurosis,  which 
is  extended  on  the  deltoides  muscle,  of  this  muscle,  of  the  infra-spin atus 
and  teres  minor,  of  the  triceps  brachii,  and  of  the  latissimus  dorsi  and 
teres  major  muscles  ;  finally,  the  posterior  circumflex  artery,  and  the 
circumflex  or  deltoid  nervous  twig,  are  divided  behind  the  shoulder. 
The  anterior  flap,  on  the  contrary,  contains,  the  skin,  the  sub-cutaneous 
cellular  tissue  ;  the  deltoides,  pectoralis  major,  biceps,  coraco-brachialis, 
and  sub-scapularis  muscles ;  the  anterior  circumflex  artery,  and  the 
parts  which  we  shall  see  in  the  axilla.  But,  finally,  if  we  prefer  the 
expeditious  mode  of  Lisfranc  and  Champesme,  we  plunge  the  knife 
into  the  coraco-clavicular  triangular  space,  pass  through  the  fibrous 
capsule,  which  is  strengthened  by  the  supra-spinatus,  infra-spinatus, 
and  teres  minor  muscles,  we  divide  the  long  tendon  of  the  biceps  in 
the  articulation,  and  then  by  withdrawing  the  instrument,  we  form  a 
flap,  which  contains  all  the  deltoides  muscle,  with  the  skin  and  fibro- 
cellular  tissue  which  covers  it,  and  also  the  latissimus  dorsi  and  teres 
major  muscles,  if  we  incline  the  point  of  the  knife  downward.  The 
acromial  and  posterior  circumflex  arteries,  and  the  deltoid  nerve,  are 
always  divided  in  this  flap  :  the  second  flap  is  composed  of  the  inner 
part  of  the  fibrous  capsule  formed  by  the  tendon  of  the  sub-scapularis 
muscle,  of  the  pectoralis  major  muscle  above,  of  the  triceps  below,  of 
the  axillary  vessels  and  nerves,  and  of  the  skin. 


4.       AXILLARY       REGION. 

The  axilla  or  axillary  region,  is  the  angle  formed  by  the  union  of 
the  trunk  with  the  thoracic  limb,  and  particularly  by  the  contact  of 
the  shoulder  and  of  the  scapulo-humeral  region  with  the  upper 
extremity. 

'Some  authors  apply  this  term  only  to  the  depression  of  the  skin, 
bounded  by  the  edge  of  the  pectoralis  major  and  latissimus  dorsi 
muscles  ;  but  we  use  it  in  a  broader  sense.  The  limits  of  the  axilla 
are  well  marked :  it  is  formed  by  the  approximation  of  regions,  which 


262  TOPOGRAPHICAL  ANATOMY. 

also  have  distinct  boundaries.  The  sinus  which  it  represents,  when 
the  parts  which  fill  it  are  removed,  has  the  form  of  a  triangular  pyra- 
mid, one  of  whose  faces  would  be  curved,  the  internal,  which  face  can 
be  distinguished  even  in  the  simple  depression  presented  by  the  skin. 
The  base  of  the  axillary  pyramid  is  situated  downward  and  outward, 
its  summit  upward  and  inward.  This  obliquity  is  caused  particularly 
by  that  of  its  costal  wall. 

The  form  and  origin  of  the  axilla,  as  we  have  said,  depend  partly 
on  the  flattening  of  the  scapular  region;  partly  on  the  convexity  of 
the  costal  region,  from  which  circumstances  these  two  bounding  regions 
do  not  correspond  exactly,  except  in  a  point,  situated  at  the  posterior 
edge  of  the  second.  This  angle  of  separation  is  changed  into  a 
complete  cavity  by  the  pectoral  muscles  anteriorly,  and  by  the  skin 
ihferiorly. 

In  order  to  study  the  axillary  space  to  advantage,  we  shall  consider 
first  its  parietes,  and  then  the  parts  it  contains. 

1.  Parietes  of  the  axilla.  Our  statement  that  the  axilla  has  a  tri- 
angular form,  naturally  leads  us  to  distinguish  in  it  three  parietes,  a 
base,  and  a  summit.  The  internal  wall  is  formed  by  the  costal  region 
of  the  thorax,  and  directly  by  the  serratus  major  muscle,  on  which 
glide  some  vessels  and  nerves,  which  we  shall  mention  hereafter.  The 
anterior  wall  is  formed  directly  by  the  pectorales  muscles,  which  sepa- 
rate at  the  angle  of  the  costal  region  :  on  examining  it  more  in  detail, 
we  find  it  formed  by  the  following  layers  from  the  skin  towards  the 
axilla  \  first,  the  skin :  second,  a  cellulo-fatty  layer,  in  the  centre  of 
which  some  fibres  of  the  platysma  and  the  supra-clavicular  filaments 
of  the  superficial  cervical  plexus  are  situated  :  third,  the  pectoralis 
major  muscle,  separated  above  from  the  deltoides  by  a  triangular  space, 
which  is  bounded  also  by  the  clavicle ;  the  extent  of  this  space  varies, 
and  in  it  the  cephalic  vein  and  the  acromial  artery  proceed  in  opposite 
directions :  fourth,  below  this  plane,  the  anterior  thoracic  vessels  and 
nerves,  curved  on  the  upper  edge  of  the  pectoralis  minor  muscle  ;  .fifth, 
this  latter  muscle,,  and  the  fascia  clavicularis,  which  continues  it  to- 
wards the  clavicle.  The  posterior  wall  is  formed  almost  entirely  by 
the  scapular  .region,  by  the  inner  part  of  the  shoulder,  and  directly  by 
the  sub-scapularis  muscle  ;  it  is  extended  anteriorly,  by  the  latissimus 
dorsi  and  teres  major  muscles,  at  which  it  comprises  ;  the  skin,  a  cel- 
lulo-fatty layer,  which  is  dense  and  continuous  with  the  infra-spinal 
aponeurosis :  more  deeply,  the  latissimus  dorsi  and  teres  major  mus- 
cles, turned  alternately  so  as  to  be  deep  and  superficial;*  the  edge  of 

* Inferiorly,- the  latissimue  dorsi  is  the  most  superficial,  from  behind  forward;  superiorly, 
the  teres  major  muscle. 


AXILLARY  REGION.  263 

this  plane,  which  is  seen  under  the  skin,  is  formed  in  almost  every 
point  by  the  latissimus  dorsi,  and  by  the  teres  major,  only  near  the 
arm  :  finally,  nearer  the  axilla,  we  find  in  this  posterior  wall,  the  com- 
mon scapular  artery,  one  branch  of  which  goes  backward,  below  the 
long  portion  of  the  triceps,  which  separates  it  from  the  circumflex 
vessels  and  nerves,  and  from  the  shoulder,  while  the  other  descends 
before  the  scapular  region  as  we  have  stated.  Of  the  angles  formed 
by  the  approximation  of  these  axillary  parietes,  two  are  internal,  an  an- 
terior and  a  posterior,  the  third  is  external.  The  first  two  are  very 
acute  :  the  internal  and  anterior  corresponds  to  the  place  where  the 
pectoral  muscles  are  detached  from  the  thorax  :  the  internal  and  pos- 
terior is  formed  by  the  separation  of  the  serratus  major  and  sub-scapu- 
laris  muscles  :  the  third,  the  external,  is  blunter  than  the  others,  and 
results  specially  from  the  union  of  the  shoulder  with  the  pectoral  mus- 
cles. The  base  of  the  axillary  pyramid,  after  the  dissection  of  the  ax- 
illa, appears  in  the  form  of  a  triangular  opening,  bounded  by  the  pec- 
toralis  major  anteriorly,  the  latissimus  dorsi  posteriorly,  the  costal  wall 
on  the  inside;  in  it  a  portion  of  a  very  follicular  skin  is  depressed, 
which  presents  long  hairs  analogous  to  those  in  the  pubis.  Under  the 
skin,  in  the  area  of  this  triangle,  which  forms  the  base  of  the  axilla, 
we  find,  a  cellulo-fatty  layer  and  some  lymphatic  ganglions,  which 
may  be  termed  superficial :  then  an  aponeurotic  layer,  which  goes 
from  the  latissimus  dorsi  to  the  pectoralis  major  muscle.  The  summit 
of  the  axilla  is  truncated,  and  dissection  shows  there  a  triangular 
opening,  the  anterior  wall  of  which  is  formed  by  the  clavicular  region, 
the  posterior  by  the  upper  edge  of  the  scapular  region,  and  the  internal 
and  inferior  by  the  first  rib:  this  opening  establishes  a  communica- 
tion between  the  axilla  and  the  supra-clavicular  region. 

2.  Axillary  cavity.  —  1.  Elements.  The  parts  contained  in  the 
axilla,  are  principally  the  nervous  and  vascular  trunks,  which  go  to 
the  upper  extremity.  We  find  there  the  axillary  artery,  which  sends 
into  the  anterior  wall  of  this  space  its  acromial  and  anterior  thoracic 
twigs ;  into  the  posterior,  its  common  scapular  and  circumflex  branches  ; 
into  the  internal,  the  long  mammary  artery.  The  axillary,  vein  accom- 
panies the  axillary  artery  in  every  part,  and  receives  branches  analo- 
gous to  those  given  ofF  by  the  artery ;  it  opens  superiorly  into  the 
cephalic  vein.  The  axilla  is  particularly  remarkable  in  respect  to  its 
numerous  lymphatic  ganglions,  which  receive  the  lymphatic  vessels  of 
the  corresponding  limb,  those  of  the  back,  mamma,  costal  region,  and 
of  the  upper  half  of  the  anterior  abdominal  or  costo-iliac  region.  The 
axillary  nerves  interlace  in  a  compact  plexus,  which  sends  its  branches 
particularly  towards  the  arm,  but  gives  some  to  the  parietes  of  the 
axilla  also ;  thus  the  anterior  thoracic  nerves  come  from  it  anteriorly, 


264  TOPOGRAPHICAL   ANATOMY. 

posteriorly  the  proper  sub-scapular  twigs,  and  the  circumflex  or  deltoid 
nerve,  on  the  inside,  the  posterior  thoracic  nerve,  the  external  respira- 
tory nerve  of  Bell.  From  this  internal  wall  also  emerge  some  nerves, 
which  pass  through  the  axilla  and  go  downward ;  they  are  the  external 
twigs  of  the  first  three  dorsal  nerves ;  finally,  the  axilla  contains  also 
some  sub-clavicular  filaments  of  the  superficial  cervical  plexus.  All 
these  parts  are  united  by  a  very  loose  lamellar  cellular  tissue,  and  by  some 
adipose  bodies.  The  cellular  tissue  of  the  axilla  communicates  very 
easily  with  that  of  the  neck,  and  directly  with  that  of  the  mediastinum : 
it  is  continuous  with  the  tissue  under  the  pleura,  by  the  openings 
through  which  pass  the  brachial  branches  of  the  intercostal  nerves. 

2.  Relations.  The  principal  axillary  vessels  and  nerves  are  united 
in  a  fasciculus,  in  which  the  vein  is  always  situated  internally  and  an- 
teriorly, while  the  artery  is  placed  at  first  above,  and  is  found  between 
this  vein  and  the  nerves  which  occupy  a  more  external  and  posterior 
point,  and  in  the  centre  of  the  axilla,  it  is  interlaced  by  the  axillary 
nerves,  particularly  by  the  double  origin  of  the  median  nerve,  which 
surrounds  it  like  a  ring ;  farther,  this  is  the  place  where  the  axillary 
plexus  terminates,  the  branches  of  which  continue  to  surround  the  ar- 
tery, but  less  directly.  This  nervous  and  vascular  fasciculus  passes 
through  the  axilla  diagonally,  or  obliquely  from  above  downward,  and 
from  within  outward,  more  and  more  remote  from  the  costal  wall ; 
this  direction  is  such,  that  at  the  upper  opening  of  the  axilla  it  is 
situated  in  the  anterior  and  internal  angle,  and  rests  on  the  first  two 
ribs  ;  while  below,  it  occupies  the  external  angle,  situated  on  the  inner 
part  of  the  shoulder.  On  the  costal  wall  of  the  axilla,  we  find  anteri- 
orly, the  long  mammary  artery,  farther  backward,  the  posterior  thora- 
cic nerve,  while  the  brachial  branches  of  the  dorsal  nerves  leave  it  and 
go  outward  toward  the  arm.  A  branch  of  the  common  scapular  artery, 
a  long  sub-scapular  nerve,  a  fasciculus  of  lymphatic  vessels  and  some 
arteries,  descend  perpendicularly  on  the  anterior  part  of  the  posterior 
wall.  The  lymphatic  ganglions  occupy  the  course  of  the  vessels,  and 
are  very  numerous  in  the  internal  and  anterior  angle,  and  under  the 
pectoral  muscles. 

Development.  As  soon  as  the  shoulder  is  distinct,  the  axilla  is 
so  likewise.  At  the  period  of  puberty,  it  increases  remarkably,  and  at 
the  same  time  some  hairs  grow  on  the  skin,  which  is  depressed  in  this 
point ;  at  the  same  period,  its  follicles  begin  to  secrete  a  musky  odor, 
which  becomes  very  strong  in  animals  at  the  period  of  rutting. 

Varieties.  The  axilla  in  the  female  is  more  superficial  than  in  the 
male  ;  but  in  return,  its  transverse  diameter  is  greater,  which  depends 
on  the  length  of  the  clavicle,  which  throws  out  the  shoulder  from  the 
trunk.  In  some  males  the  axilla  presents  the  characters  of  the  female , 


AXILLARY   REGION.  285 

from  the  same  cause ;  it  is  remarkably  narrow  in  other  individuals, 
where  the  chest  is  rounded ;  a  deviation  of  formation,  in  which  the 
scapular  region  being  raised  posteriorly,  rests  anteriorly  on  the  costal 
wall. 

Uses.  The  uses  of  the  axilla  are  evident ;  it  facilitates  the  motions 
of  the  upper  extremity,  separating  it  from  the  trunk  superiorly  ;  in  this 
respect  we  can  conceive  the  importance  of  its  depth,  and  of  the  lamel- 
lar cellular  tissue  which  fills  it.  We  must  not,  however,  think,  that 
the  freedom  of  the  motions  of  the  limb  is  proportioned  to  the  size  of 
the  axilla ;  this  idea  is  refuted  by  what  occurs  in  the  female ;  there 
are,  in  this  respect,  some  extremes,  between  which  we  find  the  forma- 
tion most  favorable  to  the  easy  play  of  the  limb  ;  this  formation  is  that 
of  the  male  in  the  normal  state.  In  adduction  of  the  arm,  the  lower 
part  of  the  axilla  is  contracted  ;  it  is  enlarged,  in  abduction  ;  in  motions 
of  the  shoulder  forward  or  backward,  the  axilla  experiences  great 
changes  ;  it  becomes  very  large  in  the  first,  but  diminishes  very  much 
in  the  second.  The  upper  opening  varies  only  in  its  dimensions  by 
the  motions  of  elevation  or  depression  of  the  shoulder ;  it  is  enlarged 
in  the  first,  and  very  much  contracted  in  the  second. 

Pathological  and  operative  deductions.  Wounds  of  the  axilla, 
even  if  not  very  deep,  are  extremely  serious,  on  account  of  the  impor- 
tant parts  situated  in  this  space.  These  wounds,  however,  are  parti- 
cularly dangerous  upward  and  inward  near  the  thorax,  and  down- 
ward and  outward  near  the  arm,  because  the  vessels  and  nerves  pass 
in  this  oblique  direction.  This  fact  should  not  be  forgotten  by  the 
surgeon,  in  operating  upon  this  part,  in  extirpating  tumors,  opening 
abscesses^  &c. ;  below,  along  the  pectoral  muscles  and  near  the  thorax, 
we  may  be  certain  of  being  far  from  the  principal  vessels.  The  long 
thoracic  artery,  which  is  situated  at  this  place,  can  alone  be  interested  ; 
but  wounds  of  this,  even,  are  by  no  means  serious.  If  a  wounding 
instrument  penetrates  into  the  axilla  from  before  backward,  it  might 
wound  the  anterior  thoracic  artery :  if  it  should  come  there  from  behind 
forward,  grazing  the  anterior  edge  of  the  scapula,  it  might  open,  in  the 
posterior  wall  and  in  the  lower  part,  the  common  scapular  artery,  or 
one  of  its  branches  ;  and  very  high  near  the  top  of  the  shoulder,  the 
circumflex  vessels  near  their  origin  ;  but  in  this  last  case,  the  axillary 
artery  might  be  injured.  Emphysema  has  been  observed  in  wounds 
of  the  axilla  ;  this  can  be  accounted  for,  by  the  alternate  motions  of 
dilatation  and  contraction,  in  the  abduction  and  adduction  of  the  arm. 

The  relation  of  the  clavicular  region  with  the  upper  opening  of  the 
axilla,  explains  the  severity  of  fractures  of  the  clavicle  with  depression, 
the  fragments  of  which  may  lacerate  the  axillary  vessels  and  nerves 
on  the  first  rib.  In  primitive  or  consecutive  dislocations  of  the  hume- 

34 


20G  TOPOGRAPHICAL  ANATOMY. 

rus  inward,  the  head  of  this  bone  is  covered  with  the  sub-scapularis 
muscle,  raises  and  compresses  the  fasciculus  of  the  vessels  and  nerves; 
hence  a  numbness  of  the  corresponding  limb.     The  axillary  artery 
may  be  compressed  in  two  parts  of  the  space  where  it  is  situated ;  first, 
on  the  second  rib,  on  which  it  rests  above ;  second,  on  the  inner  part 
of  the  top  of  the  shoulder,  below;  in  the  latter  point,  the  artery  may 
be  easily  compressed  with  a  pelote,  as  Garangeot  advises ;  in  the  first, 
on  the  contrary,  compression,  although  possible,  is  very  inefficacious, 
for  two  reasons,  even  when  made,  with  the  tourniquet  of  Dalh;.  first, 
because  it  cannot  be  made,  except  through  the  pectoralis  major  muscle, 
and  the  small  subclavian  fascia;  and  secondly,  because  the  artery, 
being  pressed  from  before  backward,  may  easily  escape  from  the  action 
of  the  compressing  power,  by  slipping  toward  the  posterior  angle  of  the 
axilla.     Ganglionnary- tumors  of  the  axilla  may  result  sympathetically 
from  a  disease  of  the  corresponding  limb,  of  the  back,  of  the  mamma?, 
of  the  superficial  part  of  the  thorax,  and  of  the  supra-umbilical  portion 
of  the  abdominal  parietes;  anatomy  demonstrates  this,  by  the  arrange- 
ment of  the  lymphatic  vessels.    .  Axillary  absce.sses  are  common  ;  some- 
times they  are  'idiopathic,  and  sometimes  result  from  purulent  abscesses 
in  the  supra-clavicular  region.     There  is  no  danger  that  abscesses,  de- 
veloped superficially  on  the  pectoralis  major,  can  come  into  the  axilla, 
through  the  triangular  space  circumscribed  by  the  pectoralis,  the  del- 
toides  muscle^and  the  clavicle,  because  the  fascia  clavicularis  forms  in 
this  direction  an  obstacle  to  its  opening  externally,  which  is  not  present- 
ed by  the  skin.     All  the  axillary  abscesses  come  below,  and  raise  the 
skin,  which  they  finally  perforate,  if  left  to  themselves  ;*  they  often  de- 
stroy the  cellular  tissue  of  the  axilla,  separate  its  parietes,  and  form  fis- 
tulae,  which' are  very  obstinate,  on  account  of  the  constant  motion  of  the 
parietes  of  this  cavity,  particularly  on  account  of  the  constant  separa- 
tion of  the  muscles  which  circumscribe  it,  which  separation  keeps  the 
opposite  faces  of  the  fistulous  opening  from  being  in  contact.     The 
axillary  artery  .and  vein  are  directly,  contiguous  above,  but  are  only 
united  by  a  loose  cellular  tissue,-  which,  perhaps,  explains  the  rarity 
of  well  marked  cases  of  varicose  aneurisms  at  this  point,  while  instan- 
ces of  false  consecutive  aneurisms  are  common.     Of  whatever  nature 
the  axillary  aneurism  may  be,  if  large,  it  raises  the  clavicular  region, 
and  contracts  in  a  measure  the  supra-clavicular  space,  where,  in  these 
cases,  the  artery  must  be  tied ;  the  inferior  aneurisms  of  the  axilla,  and 
those  of  the  upper  part  of  the  arm,  alone,  require  the  axillary  artery 
to  be  tied  in  the  axillary  region;  this  ligature  can  be  applied  only 

*  It  is  difficult  to  imagine  an  axillary  abscess  opening  spontaneously  into  the  chest,  unless 
the  costal  region  is  altered  primitively  by  the  abscess. 


BRACHIAL  REGION.  287 

through  the  anterior  wall  of  the  axilla,  and  we  always  divide  success- 
ively, the  skin,  the  sub-cutaneous  cellular  tissue,  the  pectoralis  major 
muscle,  under  which  we  must  avoid  the  anterior  thoracic  vessels  and 
nerves,  while  we  cut  the  sub-clavicular  fascia,  between  the  clavicle 
and  the  pectoralis  minor  muscle  ;  we  then  come  on  the  artery,  situated 
between  the  vein,  winch  is  anterior  and  internal,  the  brachial  plexus, 
which  is  external  and  posterior.  In  some  methods,  as  that  of  Peletan 
and  Hodgson,. we  divide  perpendicularly  the  fibres  of  the  pectoralis 
major  muscle ;  in  other  cases,  we  only  separate  its  fasciculi. 


CHAPTER     M  . 


SE.  CONDPART      OF      THE      THORACIC      LIMB. 

This  section  of  the  thoracic  limb  is  united  upward  to  the  shoulder, 
by  the  scapulo-humeral  region,  which  we  have  studied,  downward  to 
the  fore-arm,  by  the  region  of  the  elbow,  from  which  it  is  distinguished 
by  a  line  drawn  circularly  two  fingers'  breadth  above  the  epitrochlea ; 
it  includes  the  brachial  region,  and  that  of  the  elbow. 


1 .  '     BRACHIAL       REGION. 

The  arm-,  throwing  out  of  view:  its  varieties,  is  cylindrical,  and 
slightly  "compressed  transversely.  It  varies  in  length  and  size. 

The  arm  presents  four  faces,  a  posterior  and  an  anterior,  both  of 
which  are  convex ;  the  latter,  however,  more  so  than  the  former,  pre- 
senting in  the  centre  the  prominence  of  the  biceps:  the  third,  the 
internal,  presents  a  groove,  in  every  part  of  which  we  perceive  the 
pulsations  of  the  humeral  artery,  which  may  be  easily  compressed 
there  in  the  centre  :  finally,  the  latter  face  is  external,  and  is  remarka- 
ble in  the  centre,  by  a  small  depression,  situated  at  the  insertion  of  the 
deltoides  muscle:  this  is  the  .place  selected  for  the  application  of  the 
cautery. 

Structure.  —  1.  Elements.  The  arm  is  formed  of  a  bone,  of  muscles 
enveloped  by  an  aponeurosis,  of  vessels  of  every  kind,  of  nerves,  of 
cellular  and  adipose  tissuesj  all  which  parts  are  covered  and  protected 
by  the  skin.  The  bone  which  forms  the  skeleton  of  this  region  is  the 


263  TOPOGRAPHICAL  ANATOMY. 

humems,  which,  however,  presents  there  only  its  central  part,  which 
is  thin  and  compact,  and  which  consequently  is  more  fragile  than  the 
extremities.  The  muscles  are  superficial  and  deep,  are  formed,  some 
of  very  long  superficial  fibres,  and  others  of  deep  fibres,  which  are 
short,  and  are  attached  to  the  bones  :  a  great  part  of  the  triceps,  the 
biceps,  the  brachialis  internus,  the  coraco-brachialis,  exist  there,  while 
the  deltoides  presents  there  only  its  lower  extremity :  the  pectoralis 
major  and  the  latissimus  dorsi  belong,  as  we  have  seen,  to  the  top  of 
the  shoulder.  All  are  enveloped  by  the  brachial  aponeurosis,  the 
arrangement  of  which  is  very  simple.  After  forming  a  general  sheath, 
it  sends  a  very  strong  septum  from  its  internal  face^  towards  each 
lateral  edge  of  the  humerus  ;  on  the  other  side,  it  is  attached  to  the 
tendon  of  the  deltoides,  and  sends  on  it  a  very  thin  layer.  Hence,  are 
formed  three  special  sheaths  ;  an  external,  a  posterior,  and  an  anterior. 
The  artery  of  this  region  is  termed  the  brachial ;  it  is  the  continuation 
of  the  principal  trunk  of  the  thoracic  limb  ;  it  gives  off  to  the  different 
elements  around  it  numerous  branches,  three  of  which  are  extremely 
important  to  the  collateral  circulation ;  they  are  the  large  and  small 
muscular,  or  external  and  internal  collateral,  and  the  artery  of  the 
ulnar  nerve.  All  anastomose  with  the  recurrent  arteries  of  the  elbow. 
The  veins  are  superficial  or  deep-seated  ;  the  latter  follow  the  course 
of  the  arteries,  the  first  are  very  distinct  from  them ;  two  of  the  latter 
are  important,  the  common  centre  of  the  superficial  veins  of  the  hand 
and  fore-arm,  the  cephalic  and  the  basilic  veins :  the  cephalic  is  ex- 
ternal below,  and  anterior  above ;  the  basilic  is  sub-cutaneous  only  in 
the  lower  third  of  the  region ;  above,  it  is  sub-aponeurotic,  but  always 
remains  on  the  inside.  The  brachial  lymphatic  vessels  go,  some  su- 
perficially, others  deeply,  into  the  axillary  ganglions  :  most  of  them 
pass  through  this  region,  coming  from  a  lower  part  of  the  limb 
Most  of  the  brachial  nerves  are  given  off  by  five  considerable  trunks, 
all  of  which  go  towards  the  fore-arm  and  the  hand  :  some  filaments 
come  also  from  the  first  intercostal  nerves,  and  from  the  cervical  plexus. 
All  these  nerves  can  be  distinguished  into  muscular  and  cutaneous : 
the  first  come  from  the  radial,  ulnar,  median,  and  musculo-cutaneous 
nerves :  the  second  belong  to  the  supra-acromial  filaments  of  the  cer- 
vical plexus  outward  and  upward,  while  below  they  come  from  the 
cutaneous  branch  given  off  by  the  radial  nerve,  on  emerging  from  the 
radial  groove  of  the  humerus  ;  on  the  inside,  they  are  the  ramifications 
of  the  intercostal  nerves,  and  of  a  cutaneous  nerve,  which  is  always 
given  off  by  the  ulnar  nerve  very  high  in  the  axilla.  Finally,  we 
must  not  omit  the  internal  cutaneous  nerve,  which  is  also  situated  on 
the  inside,  half  of  it  deeply,  half  superficially,  but  which  only  passes 
through  the  region,  and  distributes  its  first  filaments  around  the  elbow. 


BRACHIAL  REGION.  269 

The  adipose  tissue  of  the  arm  is  abundant,  particularly  below  the  skin : 
the  skin  is  fine  anteriorly  and  internally  ;  it  is  thicker  posteriorly,  and 
has  but  little  hair. 

2.  Relations.  The  arm  is  composed  of  a  certain  number  of  super- 
imposed layers,  formed  by  the  preceding  organs,  and  common  to  every 
part  of  it,  or  confined  to  circumscribed  points.  In  proceeding  from 
the  skin  towards  the  humerus,  we  find  in  every  part  a  fine  skin, 
slightly  downy  on  the  outside,  and  attached  but  feebly,  except  at  the 
deltoides  muscle  ;  a  cellulo-fatty  layer,  which  is  very  loose  except  on 
the  point  above  mentioned,  where  also  there  is  less  of  fat,  two  things 
which  contribute  to  form  the  depression  below  the  deltoid  muscle.  A 
great  number  of  superficial  lymphatics,  veins,  and  nerves,  pass  through 
this  second  layer,  among  which  we  may  mention  particularly  ;  on  the 
inside,  the  brachial  filaments  of  the  intercostal  nerves,  which  incline 
backward ;  the  cutaneous  filament  of  the  ulnar  nerve,  which  descends 
perpendicularly  towards  the  epitrochlea ;  the  sub-cutaneous  portion  of 
the  basilic  vein  and  of  the  internal  cutaneous  nerve,  which  is  already 
divided  into  two  branches,  and  is  directed  downward  and  forward,  on 
the  outside  the  cephalic  vein  to  the  deltoid  muscle,  where  it  begins  to 
be  deep-seated,  and  finally  the  cutaneous  filaments  of  the  radial  nerve, 
which  emerge  from  the  radial  groove.  A  third  layer,  common  to  all 
the  circumference  of  the  arm,  is  formed  by  the  brachial  aponeurosis. 
More  deeply,  the  parts  of  the  arm  no  longer  form  layers,  distributed 
uniformly  in  the  periphery  of  the  region  ;  we  must  consequently  exa- 
mine their  relations  in  the  points  which  are  circumscribed  :  at  what- 
ever part  we  perforate  the  brachial  aponeurosis,  we  always  come  into 
one  of  the  three  sheaths  mentioned  above.  Most  of  the  first,  which  is 
external  and  superior,  has  already  been  examined  in  the  region  of  the 
shoulder  •  at  the  arm,  it  contains  only  the  lower  angle  of  the  deltoides 
muscle.  The  second,  the  posterior,  goes  principally  to  the  triceps 
muscle,  below  which,  on  the  humerus,  the  radial  nerve  and  the  deep 
muscular  artery  glide  obliquely  :  from  the  external  part  of  this  sheath, 
the  preceding  nerve  and  the  anterior  branch  of  the  artery  which 
attends  it,  emerge,  to  pass  into  the  anterior  sheath,  and  is  placed  be- 
tween the  brachialis  internus  and  the  supinator  longus  muscles,  while 
the  posterior  branch  of  this  same  artery  descends  perpendicularly 
toward  the  epicondyle,  always  remaining  in  the  posterior  sheath,  like 
the  trunk  from  whence  it  comes ;  near  the  inner  edge  of  the  sheath 
of  the  triceps,  we  find  inferiorly  the  ulnar  nerve  and  its  attendant 
vein  ;  both  are  directed  obliquely  towards  the  epitrochlea.  The  third 
sheath  is  anterior,  and  belongs  in  common  to  the  biceps  muscle,  which 
is  situated  superficially,  the  coraco-brachialis  and  the  brachialis  internus 
muscles,  situated  inferiorly:  we  find  the  external  cutaneous  nerve 


270  TOPOGRAPHICAL    ANATOMY. 

between  them,  which  passes  at  the  upper  part  through  the  coraco- 
brachialis  muscle.  This  sheath  contains,  at  its  external  and  inferior 
part,  as  has-been  said,  the  trunk  of  the. radial  nerve  and  an  arterial 
branch;  at  its  inner  part,  on  the  contrary,  it  encloses  in  its  whole 
extent  the  humeral  artery  and  its  two  attendant  veins,  and  also  the 
median  nerve,  the  relations  of  which  with  these  vessels  are  extremely 
important:  this  nerve  is  external  above,  anterior  in  the  centre,  and 
internal  below.  Superiorly,  we  find  this  nervous  and  vascular 
fasciculus  joined  by  the  ulnar  nerve,  which  soon  leaves  the  inner 
part  of  the  brachial  artery,  and  penetrates  into  the  posterior  sheath, 
where  it  has  already  been  mentioned  ;  finally,  the  internal  cutaneous 
nerve,  the  cutaneous  filament  of  the  ulnar  nerve,  and  the  basilic  vein, 
which  is  situated  deeply  for  a  little  space,  and  soon  passes  obliquely 
through  the  aponeurosis,  and  goes  to  the  skin. 

Development.  In  the  formation  of  the  upper  extremity,  the  arm  is 
distinguished  the  third.  In  fact,  it  appears  after  the  hand  and  fore- 
arm, and  before  the  shoulder: 

Varieties.  In  the  male,  the  external  prominences  of  the  deltoides, 
the  anterior  of  the  biceps,  and  the  posterior  of  the  triceps,  are  'much 
more  distinct  than  in  the  female.  These  prominences,  added  to  the 
small  quantity  of  sub-cutaneous  fat,,  render  the  antero-posterior  diameter 
of  the  arm  much  larger  in  the  male  than  the  transverse.  In  the  fe- 
male, the  anterior  and  posterior  muscles  are  thin,  the  sub-cutaneous  fat 
abounds  on  the  sides,  which  gives  the  arm  a  nearly  rounded  form ;  in 
her,  also,  en  bon  point  effaces  the  relief  of  the  basilic  and  cephalic  veins, 
and  the  depression  of  the  deltoides  muscle,  so  visible  in  the  male.  We 
often  find  in  the  region  of  the  arm  two  principal  arterial  trunks,  in  con- 
sequence of  the  premature  division  of  the  brachial  artery.  Meqkel  ob- 
serves, and  very  justly,  that  one  of  the  supernumerary  'branches  in 
these  cases,  is  sometimes  and  most  frequently,  the  radial,  and  some- 
times the  inter-osseous  artery ;  in  this  case,  the  brachial  artery  exists 
in  its  normal  position,  and  has  its  common  relations ;  the  abnormal 
branch,  on  the  contrary,  exists  more  superficially  on  the  inside  of  the 
first,  sometimes  even,  as  Meckel  states,  under  the  skin  of  the  arm ;  this 
position,  however,  is  very  rare,  for  we  have  seen  twenty-three  cases 
of  the  premature  division  of  the  brachial  artery,  and  have  never  seen 
one  instance  of  it.  We  have  once  seen  the  artery  divide  above,  and 
unite  below.  Meckel  mentions  instances  of  this  arrangement.  These 
varieties  are  important  in  operations  on  the  arm,  especially  in  applying 
ligatures  to  the  brachial  artery. 

Pathological  and  operative  deductions.  The  arm  is  sometimes 
entirely  deficient,  the  last  two  sections  of  the  limb  existing ;  sometimes 
it  is  rudimentary.  The  brachial  artery  must  be  .compressed  at  the 


BRACHIAL  REGION.  271 

inner  and  central  part  of  the  arm;  there,  in  fact,  this  vessel  is  situated 
superficially,  arid  it  is  separated  from  the  humerus  only  by  the  expand- 
ed tendon  of  the  eoraco-brachialis  muscle,  and  consequently,  the  bone 
furnishes  a  point  of  support,  sufficient  fox  the  compression  of  this  ves- 
sel. Wounds  of  the  inner  part  of  the  arm  are  more  dangerous  than 
those  of  the  other  parts,  since  there,  only,  the  large  nervous  and  vas- 
cular trunks  are  situated;  nevertheless,  a  posterior  and  central  wound, 
made  by  an  instrument  which  penetrates  to  the  b'one,  besides  being 
attended  with  a  profuse  hemorrhage  from  the  external  collateral  artery, 
might  also,  as  we  have  seen  at  the  Hospice  Bicetre,  be  followed  with 
a  paralysis  of  the  extensor  muscles  of  the  hand  and  fingers;  in  fact, 
the  radial  nerve  had  been  divided.  .  Fractures  of  that  part  of  the  hu- 
merus which  belongs  to  this  region,  are  always  accompanied  with  a 
change  in  the  form  or  the  length  of  the  arm.  If  the  fracture  .occur 
above  the  insertion  of  the  deltoides  muscle,  this  muscle  draws  upward 
the  lower  fragment  to  which  it  is  attached,  and  the  tipper  fragment  is 
drawn  inward  by  the  pectoralis  major,  and  latissimus  dorsi ;  there  is 
at  first  a  displacement,  and  then  a.  shorten  ing.  If,  on  the  contrary,  the 
fracture  occurs  below  the  deltoides  muscle,  the  upper  fragment  may 
be  kept  motionless  between  the  opposite  powers  of  the  deltoides,  latis- 
simus dorsi,  and  pectoralis  major  muscles  :  but  most  frequently  it  is 
thrown  outward,. by  the  more  powerful  action  of  the  former  ;  the-  lower 
fragment  is  then  loosely  drawn  upward,  by  the  biceps  and  triceps. 
Finally,  when  the  fracture  is  situated  at  the  attachments  of  the  bra- 
chialis  internus  and  triceps  muscles,  the  -displacement  is  very  slight, 
because  these  muscles  are  inserted  in  both  fragments.  The.  fracture 
must  be  very  near  the  elbow,  for  the  displacement  which  supervenes  to 
resemble  that  which  occurs  in  dislocation  of  this  region  ;  we  shall 
mention  this  hereafter.  Inflammation  of  the  arm  presents  nothing  pe- 
culiar ;  on  the  inside  of  it,  we  sometimes  see  red  lines,  which  mark 
the  lymphatic  vessels ;  these  elements,  also,  are  inflamed  and  tense,  a 
common  symptom  in  inflammations  of  the  lower  sections  of  the  limb. 
The  arm  may  be  amputated  by  the  circular,  or  by  the  flap  operation  : 
when  the  latter  mode  is  chosen,  the  flaps  should  be  lateral,  first,  be- 
cause on  the,  sides,  and  particularly  on  the  inside,  the  most  important 
organs  are  situated,  and  also  in  order  to  have  the  wound  united  in  an 
antero-posterior  direction,  which  also  is  advantageous  after  the  circular 
operation.  The  predominance  .of  the  antero-posterior  diameter  of  the 
arm,  explains  the  advantage  of  an  antero-posterior  union  in  this  ope- 
ration, after  which,  we  must  always  tie  the  brachial  artery,  the  great 
collateral  artery,  and  the  artery  of  the  ulnar  nerve :  the  small  muscular 
artery  is  cut  in  the  stump,  only  when  the  limb  is  amputated  near  the 
elbow.  If  called  upon  to  tie  the  brachial  artery,  in  case  of  a  wound 


272  TOPOGRAPHICAL    ANATOMY. 

or  an  aneurism,  we  must  remember  distinctly  its  triply  variable  posi- 
tion, relative  to  the  median  nerve,  which  must  be  taken  for  a  guide : 
superiorly,  we  must  look  for  it  on  the  inside  of  it,  and  on  the  outside 
of  the  ulnar  nerve ;  in  the  centre,  we  must  be  extremely  careful  not  to 
touch  the  median  nerve,  which  it  crosses,  sometimes  before,  sometimes 
behind  it :  inferiorly,  we  must  always  look  for  it  on  the  outside  of  this 
nerve ;  the  ulnar  nerve  has  no  longer  any  relation  with  it,  and  cannot 
be  injured.  A  very  important  precept  in  tying  this  artery  readily,  is 
founded  on  the  manner  in  which  it  is  joined  in  every  part  to  the  inner 
edge  of  the  biceps,  it  being  situated  in  the  sheath  of  this  muscle.* 
When  we  attempt  to  tie  this  vessel  in  the  cadaver,  we  can  see  the  jus- 
tice of  these  remarks,  at  the  same  time  that  we  find  it  difficult  to  per- 
form this  operation,  if  we  cut  too  much  on  the  inside ;  for  then,  in 
order  to  find  the  brachial  artery  in  the  middle  of  the  arm,  we  divide 
the  skin,  the  sub-cutaneous  cellular  tissue,  and  the  aponeurosis ;  sepa- 
rate and  avoid  the  internal  cutaneous  nerve,  the  basilic  vein,  the  ulnar 
nerve,  and  then  we  find  the  artery  contiguous  to  the  median  nerve : 
farther,  we  have  shown  that  the  course  of  this  vessel  may  be  repre- 
sented by  an  imaginary  line,  drawn  from  the  inner  part  of  the  shoulder 
to  the  centre  of  the  anterior  face  of  the  elbow :  in  this  direction  the  in- 
cisions must  be  made,  when  we  wish  to  apply  a  ligature  to  the  artery. 
The  cautery  should  be  applied  to  the  depression  below  the  deltoides 
muscle,  because  in  this  part  there  is  no  deep-seated  muscle,  the  con- 
traction of  which,  by  disturbing  the  ulcerated  surface,  might  cause 
pain. 


2.      REGION      OF      THE       ELBOW. 

The  elbow  is  a  region  formed  by  the  angular  union  of  the  second 
and  third  sections  of  the  upper  extremity. 

Its  natural  limits  are  vague  ;  farther,  we  may  state  that  it  is  formed 
by  all  the  organs  which  surround  the  humero-cubital  articulation. 
Nevertheless,  to  confine  the  study  within  certain  limits,  and  to  facili- 
tate the  dissection  of  the  elbow,  we  will  say  that  it  commences  one 
finger's  breadth  above  the  epitrochlea  and  extends  to  two  below  it. 

This  region  is  remarkable  for  the  extent  of  its  transverse  diameter; 
however  much  the  fore-arm  may  be  extended,  the  elbow  always  forms 
an  evident  angle,  which  projects  backward  and  is  open  anteriorly ; 
anteriorly,  also,  it  presents  a  triangular  depression,  in  which  we  feel 

*  Open  the  sheath  of  the  biceps  at  its  inner  part,  and  you  will  readily  find  the  brachial 
artery,  in  the  relations  we  have  stated,  with  the  median  nerve. 


REGION  OF  THE  ELBOW.  273 

the  pulsations  of  the  brachial  artery ;  it  is  bounded  laterally  by  two 
prominences,  the  external  of  which  is  particularly  developed  ;  the  latter 
is  formed  by  the  fasciculus  of  the  external  muscles  of  the  fore-arm,  and 
the  other  by  the  pronator  teres  muscle.  The  triangular  depression  of 
which  we  are  speaking  is  divided  above  into  two  parts,  by  the  promi- 
nence of  the  tendon  of  the  biceps  muscle  ;  the  external  is  very  distinct, 
and  we  see  there  the  median  cephalic  vein  through  the  skin  ;  the  in- 
ternal is  more  superficial,  and  presents  the  oblique  course  of  the  median 
basilic  vein,  and  it  is  also  remarkable  for  the  pulsations  of  the  humeral 
artery.  Farther,  on  the  outside,  the  superficial  radial  vein,  and  on  the 
inside,  the  two  ulnar  veins  are  very  well  marked  externally ;  we  now 
have  a  complete  idea  of  this  important  face  of  the  elbow. 

On  the  sides  of  this  region,  in  thin  individuals,  are  the  two  promi- 
nences of  the  condyles  of  the  humerus,  the  internal  of  which  is  more 
distinct  and  more  elevated  than  the  external ;  in  fat  individuals, 
on  the  contrary,  we  see  at  the  same  parts  two  depressions.  Pos- 
teriorly we  perceive  the  olecranon  process,  the  position  of  which 
varies  in  the  motions  of  the  fore-arm  ;  if  w'e  compare  it  with  that  of  the 
tuberosities  of  the  humerus  which  are  fixed,  we  find  that  in  the  forced 
extension,  the  olecranon  rises  above  them,  that  it  corresponds  to  them 
when  the  arm  is  semi-flexed,  and  finally,  that  it  is  much  below  when  the 
arm  is  flexed  at  a  right  angle  only,  and  a  fortiori  when  the  flexion  is 
extreme.  On  the  sides  of  the  olecranon  process,  this  face  of  the  elbow 
is  bounded  by  two  depressions;  the  internal  particularly  is  very  much 
marked  ;  pressure  on  this  part  causes  pains,  which  extend  to  the  little 
finger  and  the  inside  of  the  ring-finger. 

Structure.  —  1.  Elements.  The  humero-cubital  articulation  forms 
the  base  on  which  all  the  other  elements  of  the  elbow  are  situated ; 
this  articulation  is  strengthened  by  four  ligaments,  of  which  the  two 
latter,  particularly,  are  very  strong  and  very  compact,  and  it  is  formed 
by  the  inferior  extremity  of  the  humerus,  and  the  upper  part  of  the  two 
bones  of  the  fore-arm,  which  are  united  by  a  small  articulation  which 
blends  entirely  with  it,  and  which  also  belongs  to  the  region  of  which 
we  are  s-peaking.  The  cavity  formed  by  this  small  articulation  on  the 
side  of  the  ulna  is  lower  posteriorly  than  anteriorly.  We  will  also 
state  that  the  humero-cubital  articulation  is  formed  in  such  a  manner, 
and  the  ulna  is  fitted  so  intimately  in  the  pulley  of  the  humerus,  that 
it  admits  only  the  motions  of  flexion  and  extension  of  the  fore-arm ;  if 
we  examine  the  separate  motions  of  the  ulna  and  the  radius  on  the 
humerus,  we  observe,  in  regard  to  the  ulna,  that  it  can  only  be  flexed 
or  extended  on  the  humerus  ;  while  the  radius  is  united  to  the  humerus 
very  loosely,  so  that  it  rotates  upon  this  bone,  and  would  even  incline 
to  the  side,  if  it  was  not  supported  by  the  ulna,  which  is  motionless  in 

35 


274  TOPOGRAPHICAL  ANATOMY. 

this  direction,  and  which  serves  as  a  splint  for  it.  The  triceps,  the 
biceps,  the  brachialis  intermis,  all  the  external  muscles  and  the  posterior 
superficial  muscles  of  the  fore-arm  attached  to  the  epicondyle  and  the 
outer  edge  of  the  humerus,  all  the  anterior  superficial  muscles  of  the 
same  region  attached  to  the  epitfochlea,  these  are  the  organs  of  mo- 
tion found  in  the  elbow,  and  to  which  they  belong  but  slightly, -except 
the  anconeus  muscle,  most  of  which  is  situated  there.  The  aponeu- 
rosis  of  the  elbow  adheres  intimately  to  the  tuberosities  of  the  humerus, 
and  to  the  olecranon  process,  and  thence  extends  between  the  muscles 
to  which  it  gives  points  of  insertion,  forming  sheaths  for  them,  which 
will  be  described  when  speaking  of  the  fore-arm.  Upward  and  forward, 
on  the  tendon  of  the- biceps,  the  aponeurosis  of  the  arm  is  continuous 
with  that  of  the  elbow,  most  of  its  fibres  bending  toward  the  internal 
fasciculus  of  the  anti-brachial  muscles,  and  only  sending  some  filaments 
to  the. external.  In  the  place  where  the  fibres  -of  this  aponeurosis 
separate  in  these  opposite  directions,  are  two  foramina ;  one  through 
which  the  external  cutaneous  nerve  leaves  its  deep  position,  and  soon 
goes  into  the  thin  sheath  of  the  median  vein  ;  the  other,  a  little  below, 
which  contains  an  anastomptic  venous  twig  of  the  superficial  and 
deep  veins.  The  aponeurosis  of  the  e.lbow  is  very  much  strengthened 
interiorly,  by- two  expansions  ;  one"  is  stronger  and  rises  from  the  inner 
edge  of  the  tendon  of  the  biceps,  and  goes  downward  and  inward  ;  the 
other  is- weaker  and  rises  from  the  outer  edge  of  the  tendon  of  the 
brachialis  internus,  and  goes  on  the  external  muscular  fasciculus  of  the 
.fore-arm.  At  the  hollow  of  the  elbow,  the  aponeurosis  of  its  inner  face 
sends  toward  the  anterior  part  of  the  tendon  of  the- brachialis  internus 
muscle .  a  layer,  which  leaves;  the  .biceps  on  the  outside,  and  which 
forms  with  the  expansion  of  the  brachialis  internus  above  described,  a 
sheath  for  the  tendon  of  the  biceps.  The  brachial  artery  terminates 
in  this  region,'  in  the  centre  of  the  elbow,  and,  consequently,  the  radial 
and  ulnar  arteriejs  commence'  here.  The  radial  artery  separates  from' 
it  in  the  course  of  a  line,  supposed  to  be  drawn  from  this  point  toward 
the  styloid  process  of  the  radius  ;'  the  ulnar  artery  in  the  course  of 
another  line,  always  drawn  from  the  centre  of  the  elbow  to  the  union 
of  the  upper  with  the  two  lower  thirds  of  the  fore-arm.  The  vessels 
which  only  pass  through  the  region,  leave  there  four  branches,  which 
are  termed  the  external  and  internal  recurrent  radial -and  ulnar  arte- 
ries. Two  of  these  are  situated  on  the.  inside,  and  are  given  off  by  the 
ulnar  artery ;  two  others  6n  the  outside,  an  anterior  from  the  radial 
artery,  a  posterior  from  the  dorsal  inter-osseous  artery.  The  large  and 
small  muscular  arteries  of  the  arm,  and  the  artery  of  the  ulnar  nerve, 
also  terminate  here,  anastomosing  with  the  first  so-  as  to  form,  around 
the  epitrocblea  and  epicondyle  some  arterial  circles,  which  are  ex- 


REGION  OF  THE  ELBOW.  .  -275 

tremely  important  to  the  collateral  circulation.  The  veins  of  the  elbow- 
are  superficial  or  deep-;  the  latter  follow  the  course  of  the  arteries, 
each  of  which  has  generally  two  veins  ;  nevertheless,  there  is  fre- 
quently  only  one  brachial  vein,  but  always  two  radial  and  two  ulnar 
veins.  The  superficial  veins  are  numerous,  and  are  situated  anteri- 
orly;  in  the  normal  state,  they  .unite  in  four  principal  trunks  ;  an  ex- 
ternal trunk  is  formed  by  the  end  of  the  superficial  radial  vein  ;  one, 
and  often  several,  which  are  internal,  belong  to  the  anterior. and  poste- 
rior superficial  ulnar  veins  ;  finally,  two  middle  veins  are  formed  by 
the  median  basilic  and  median  cephalic  veins,  which  are  formed  by 
the  bifurcation  of  the  small  median  vein  of  the  fore-arm,  and  anasto- 
mose broadly  at  their  origin  with,  the  deep  radial  veins.  The  lymphatic 
vessels  are  very  numerous  anteriorly  and  superficially;  deeply,  they_ 
form  a  small  fasciculus  on  each  of  the  arteries ;  all  go  into  the  axillary 
ganglions  ;  some  of  them,  the  most  internal,  pass  through  one  or  two 
ganglions  which  are  constantly  situated  above  the  epitrochlea.  At. the 
base  of  the  hollow  of  the  elbowj  on  or  near  the  brachial  artery,  we 
have  also  found  one  or  two  small  lymphatic  ganglions. 

The  nerves  of  the  elbow  are  "divided  into  sub-cutaneous  and  sub- 
aponeurotic ;  the  first  •  are,  the  filame'nts  of  the  external  cutaneous 
nerve,  which  is  divided  into  three  branches,  -then  the  trunk  of  the 
internal  cutaneous  nerve,  which  becomes  more  superficial,  the: cuta- 
neous branch  of  the^ulnar  nerve,  and  those  of  the  radial  nerve.  The 
sub-aponeurotic  nerves  are  the  median,  the  ulnar,  and  the  radial  nerves, 
which  divide  here  into  two  branches,  one  of  which  turns  round  the 
neck  of  the  radius  below  the  supinator  brevis,  while  the  other  is  a 
continuation  of  the  trunk.  The  cellular  tissue  is  abundant,  anteriorly; 
but  less  exists  in  the  other  parts  ;  the  sub-cutaneous  is  very  loose  pos- 
teriorly, and  it  is  lamellar  and  often  replaced  by  a  mucous  bursa ;  this 
tissue  is  a  little  more  compact  anteriorly,  but  much  more. so.  on  the 
sides,  at  the  condyles  of  the  humerus  ;  but  little  fat  is  developed  in  the 
sub-cutaneous  tissue,  except  anteriorly:  under  the  aponeurosis, .  it 
exists,  particularly  in  the  hollow  of  the  elbow,  around  the  vessels,  and 
in  the  base  of  the  olecranon  and  the  coronoid  cavities ;  .in  the  last 
two  points,  it  forms  elastic  cushions.  The  skin  is  remarkable  only 
for  its  fineness,  which  is  seen  particularly  anteriorly. 

2.  Relations.  All  this  region  is  surrounded  by  the  skin,  which  is 
united,  to  the  deep  parts ;  first,  posteriorly,  by  a  very  loose  cellular 
tissue,  or  by  a  mucous  bursa  ;  second,  by  a  dense  cellular  tissue  at  the 
tuberosities  of  the  humerus ;  third,  anteriorly,  by  a  cellulo-fatty  tissue, 
which  is  moderately  dense  ;  in  this  layer,  we  find  in  every  part  nerves, 
lymphatic  vessels,  and  veins  ;  but  most  of  their  trunks  are  situated 
anteriorly.  The  posterior  sub-cutaneous  nerves  are  twigs  of  the  radial 


276  TOPOGRAPHICAL  ANATOMY. 

and  of  the  cutaneous  ulnar  nerve ;  the  anterior  belong  to  the  external 
and  internal  cutaneous  nerves  ;  the  external  cutaneous  nerve  passes, 
without  Dividing,  behind  the  median  cephalic  vein,  to  which  it  is  not 
directly  contiguous,  as  authors  assert ;  the  three  twigs  of  the  internal 
cutaneous  nerve,  after  dividing,  interlace,  on  the  contrary,  around  the 
median  basilic  vein,  which  is  situated  directly  upon  it.     These  two 
veins  are  directed  obliquely  inward  or  outward,  to  unite  with  the 
superficial  radial  and  ulnar  veins,  which  are  more  external.     Next 
comes  the  aponeurosis ;  it  surrounds  the  whole  region,  like  the  skin, 
but  differs  from  it  in  respect  to  the  septa,  which  it  sends  deeply.     The 
aponeurosis  being  removed,  as  the  relations  vary  anteriorly,  posteriorly, 
and  on  the  sides,  they  must  be  followed  successively  in  these  different 
points ;  anteriorly,  we  discover  a  triangular  space,  bounded  on  the 
outside  by  the  fleshy  mass  of  the  supinator  and  radiales  externi  muscles, 
which  mass  is  kept  in  place  by  a  sheath,  where  we  find  also  the  radial 
nerve,  and  the  anterior  vascular  plexus  of  the  epicondyle ;  this  space 
is  bounded  on  the  inside  by  the  fasciculus  of  the  radial  muscles,  and 
particularly  by  the  pronator  teres,  which  is  divided  above,  the  palmaris 
longns  and  brevis  placed  anteriorly,  and  the  flexor  sublimis  inferiorly, 
all  of  which  are  retained  in  a  general  sheath,  where  the  anterior  anas- 
tomosing arterial  plexus  of  the  epitrochlea  is  situated ;  finally,  the 
base  of  this  space  is  formed  by  the  brachialis  internus  above,  the  flexor 
profundus  and  the  supinator  brevis  below.     The  tendon  of  the  biceps 
separates  this  hollow  of  the  elbow  into  two  portions ;  an  external,  into 
which  pass  the  radial  nerve  and  the  anterior  arterial  plexus  of  the 
epicondyle,  which  are  specially  situated  in  the  sheath  mentioned ;  the 
other,  internal,  which  contains  with  the  anterior  arterial  plexus  of  the 
epitrochlea,  the  median  nerve  on  the  inside,  and  the  brachial  artery 
on  the  outside.     We  remark  that  the  brachial  artery  and  the  preceding 
nerve  are  separated  from  the  median  basilic  vein  only  by  the  aponeu- 
rotic  expansion  of  the  biceps,  but  that  in  descending  into  the  hollow 
of  the  elbow,  they  proceed  posteriorly,  and  consequently  separate  far 
from  the  vein.     Posteriorly,  the  aponeurosis  being  removed,  we  find ; 
the  tendon  of  the  triceps,  the  olecranon  process  intimately  united  to  the 
aponeurosis,  and  the  upper  extremity  of  the  anconeus,  extensor  carpi 
ulnaris,  extensor  minimi  digiti  proprius,  and  extensor  digitorum  com- 
munis  muscles  ;  finally,  under  the  triceps,  the  humerus  and  the  pos- 
terior ligament  of  the  articulation ;  under  the  four  muscles  of  the 
fore-arm,  we  find  the  upper  extremities  of  the  radius  and  ulna,  and 
their  superior  rotatory  articulation ;  we  find,  on  the  inside,  first,  the 
depression,  bounded  by  the  epitrochlea  and  the  olecranon,  to  which  parts 
the  aponeurosis  adheres  intimately,  thus  forming  an  arch,  on  which 
the  upper  extremity  of  the  extensor  carpi  ulnaris  muscle  is  partially 


REGION  OP  THE  ELBOW.  277 

attached ;  second,  below  this  tendinous  arch,  the  ulnar  nerve  and  the 
posterior  arterial  plexus  of  the  epitrochlea,  then  the  radiated  internal 
lateral  ligament.  On  the  outside,  is  situated  the  fleshy  mass,  which 
forms  the  outer  side  of  the  hollow  of  the  elbow  ;'  this  mass  is  formed 
from  without  inward,  by  the  supinator  longus,  the  radialis  externus 
longior,  the  brevior,  and  the  supinator  brevis,  under  which  we  find 
the  dorsal  branch  of  the  radial  nerve,  which  is  directed  obliquely 
downward  and  backward,  and  rests  almost  directly  against  the  bone. 

Development.  In  early  life,  the  tuberosities  are  slightly  marked, 
the  olecranon  process,  particularly,  is  lower,  whence  it  follows  that 
the  extension  can  be  carried  farther  than  in  the  adult,  and  consequently 
hat  the  angle  of  the  elbow  is  not  so  marked.  At  the  same  period,  the 
small  sigmoid  cavity  of  the  ulna  is  superficial,  and  the  annular  liga- 
ment of  the  radius  is  much  more  extensive. 

Varieties.  When  the  brachial  artery  divides  prematurely,  the  ulnar 
artery  frequently  does  not  descend  into  the  hollow  of  the  elbow ;  it 
preserves,  in  the  fore-awn,  its  superficial  position  under  the  aponeurosis  ; 
it  has  even  been  seen  directly  under  the  skin.  We  shall  mention  these 
varieties  hereafter. 

In  the  female,  the  accumulation  of  fat  anteriorly,  enlarges  the  elbow 
in  this  direction ;  it  is  more  round  than  in  the  male,  from  the  same 
cause,  and  also  because  the  lateral  muscles  project  less  in  her. 

Pathological  and  operative  deductions.  Wounds  of  the  elbow  may 
be  very  serious,  particularly  anteriorly  and  internally,  where  the  hu- 
meral artery  is  situated.  A  simple  contusion  of  the  posterior  part  is 
very  painful,  because  in  this  part  the  skin  rests  directly  against  the 
olecranon  process,  which  furnishes  a  point  of  support  to  the  acting 
power :  in  these  cases,  we  see  the  importance  of  the  sub-cutaneous 
mucous  bursa ;  it  facilitates  the  yielding  of  the  skin,  which  would 
otherwise  be  broken  :  injuries  of  the  olecranon  process,  or  the  epi- 
trochlea, affect  more  or  less  the  ulnar  nerve  situated  between  them ; 
hence,  another  source  of  the  pains  which  extend  toward  the  little 
finger  ;  finally,  if  the  external  violence  be  greater,  it  causes  fractures, 
the  olecranon  process  is  particularly  exposed  to  them,  and  next  the 
epitrochlea.  In  fractures  of  the  olecranon  process,  the  upper  fragment 
is  always  drawn  upward  by  the  triceps  ;  it  is  also  extremely  difficult 
to  keep  this  fragment  near  the  other,  unless  the  fore-arm  is  extended ; 
we  must,  however,  remember  the  angle  naturally  formed  by  the  elbow, 
and  in  applying  the  bandage  we  must  not  carry  the  extension  too  far, 
if  we  wish  to  restore  the  limb  to  its  proper  shape,  and  at  the  same  time 
to  render  it  as  useful  as  possible,  if  anchylosis  of  the  elbow  occur,  as 
sometimes  happens.  The  humerus  may  be  fractured  directly  above 
its  condyles ;  the  lower  fragment  is  then  very  short,  and  is,  as  it  were, 


278  TOPOGRAPHICAL  ANATOMY. 

united  with  the  bones  of  the  fore-arm,  and  moves  with  them ;  it  is 
balanced  between  two  forces,  by  the  traction  anteriorly  of  the  brachialis 
internus  and  biceps  muscles,  and  by  that  of  the  triceps  posteriorly  5 
but  the  superior  force  of  this  latter  finally  draws  the  oleeranon  process 
upward,  and  causes  the  fragment  which  holds  it  there  to  vibrate,  so 
that  its  upper  extremity  goes  forward;  and  the  inferior  upward  and 
backward ;  hence,  a  prominence  of  the  elbow,  similar  to  that  seen  in 
Dislocation  posteriorly,  but  which  differs  from  it,-  as,  in  this  case,  the 
deformity  is  attended  with  no  change  in  the  normal  relation  of  the 
three  tuberosities.  Dislocations  of  the  elbow,  which  are  also  termed 
dislocations  of  the  fore-arm,  seldom  occur  ;  in  order  for  the  bones  of  the 
fore-arm  to  be  thrown  forward}  the  oleeranon  process  must  be  fractured, 
and  then  the  injury  would  be  severe.  The  resistance  of  the  lateral 
ligaments,  and  particularly  the  compactness  of  the  articulation,  prevent 
lateral  dislocations  in  a  great  measure,  which  cannot  supervene,  unless 
most  of  the  ligaments -are  broken ;  and  notwithstanding  the  dislocation 
may  be  favored  by  these  circumstances,  jt  is  generally  imperfect. 

After  dislocation  posteriorly,  in  simple  cases,  the  pulley  of  the  hu- 
merus is  kept  on  the  summit  of  the  coronoid  process,  by  the  tendon  ot 
the  brachialis  internus  muscle,  which  tendon. is  very  much  depressed, 
and  which,  when  the  dislocation  is  overlooked,  may  ossify,  and  thus 
form  a  new  articular  cavity,  an  instance  of  which  was  seen  by  Beclard. 
In  dislocations  posteriorly,  the  humerus  sometimes  tears  the  soft  parts 
and  projects  anteriorly ;.  in  these  cases,  the  brachial  artery  is  very 
liable  to  be  ruptured ;  dislocation  of  the  radius  on  the  ulna,  generally 
takes  place  posteriorly,  because  the.  edge  of  the  cavity  of  the  latter  is 
lower  in  this  direction  ;.  it  is  frequent  in  children;,  in  whom  the  ulnar 
cavity  is  rudimentary.  • 

Hydarthrosis  of  the  elbow  appears  at  first  posteriorly,  on  the  sides 
of  the  oleeranon  process  and  of  the  tendon  of  the  triceps  muscle,  where 
the  articulation  is  less  supported,  and  the  tumor  then  rises  between 
the  .triceps  and  humerus.  Brasdor  has  proposed  to  amputate  the  fore- 
arm, by  disarticulating  it  in  the  region  of  the  elbow,  and  making  one 
anterior  flap ;  this  operation  is  founded  on  the  anatomy  of  the  elbow, 
since  the  large  trunks  of  the  nerves  and  vessels,  and  the.  largest  mus- 
cles are  situated  in  this  part :.  the  posterior  flap  would  be  very  thin ; 
in  this  operation,  we  must  not  forget  that  the  articulation  is  situated 
one  finger's  breadth  below  the  epitrochlea,  that  it  is  loose  on  the  out- 
side, and  that  the  knife  can  be  introduced  in  that  part  only.  Dupuy- 
tren  has  advised  an  ingenious  modification  of  Brasdor's  method ;  it 
consists  in  sawing  off  the  oleeranon  process,  which,  anchylosing  in  its 
humeral  cavity,  would  furnish  a  fixed  point  of  action,  very  useful  to 
the  triceps  muscle.  Notwithstanding  this  process,  all  practitioners 


REGION  OF  THE  ELBOW.  279 

prefer  the  operation  of  Brasdor.     Park  first  attempted  the  resection 
of  the  ends  of  the  elbow,  in  case  of  caries  ;  Roux  and  Dupuytren  have 
also  performed  this  great  operation  successfully.     They  always  ope- 
rate on  the  posterior  part  of  the  elbow,  where  the  bones  are  situated 
more  superficially,  and  are  less  covered  with  important  parts.     The 
ligature  of  the  brachial  artery  requires  only  the' division  of  the  skin,  of 
the  sub-cutaneous  cellulo-fatty  tissue,  and  of  the  aponeurosis.  We  easily 
avoid  the  median  nerve :  it  is  situated  on  the  inside,  arid  is  slightly 
separated  from  the  artery.     Venesection  may  be  performed  on  all  the 
veins  of  the  elbow  ;  it  is  free  from  danger  when  the  superficial  radial 
or  ulnar  veins  are  opened  ;  this  is  not  true  when  the  median  basilic 
or  cephalic  veins  are  selected,  which,  are  generally  chosen  on  account 
of  their  size,     In  bleeding  from  the  median  basilic  vein,  if  the  lancet 
be  introduced  deeply,  the  braehial  artery  may  rje  wounded,  which  is 
always  a  very  serious  accident;  if  the  vein,  however,  be  opened  lower, 
down,  this  risk  is  avoided,  because-  the.  artery  is  there  situated  much 
more  deeply;  when,  however,  the  ulnar  artery  remaius  superficial,  it 
may  .be  wounded  by  a  careless  physician  ;•  finally,  numerous  filaments 
of  the  inferior  cutaneous  nerve  may  be  wounded  in  this  operation ; 
hence,  severe  pains,  which  extend  in  the  direction  of  .these  nerves. 
The  brachial  artery  cannot  be  wounded,  when  the  median:  cephalic 
vein  is  opened ;  in  this  case,  can  the  nerves  be  injured  ?  this  is  difficult, 
unless  the  lancet  is  introduced  very  deeply :  in  fact,  the  external  cuta- 
neous nerve  passes  far  behind  the  vein,  and  is  not  directly  contiguous 
with  it ;  farther,  it  is  single,  which  circumstances  protect  it  to  a  certain 
point;  thus,  we  must  open, .if  -possible,  the  -median  cephalic  vein.     If 
the  brachial  artery  has  been,  wounded  extensively,  it  nrast  be  tied 
above  and  below  the  injury,  because  the  arterial  plexuses  of  the  epi- 
condyle  and  the  epitrochlea,  which  are  so  important  in  other  cases  to 
re-establish  the  circulation,  would  cause  the  hemorrhage  to  re-appear; 
if,  on  the  contrary,  the  artery  is  simply  pricked,. as  in  venesection,  the 
wound  must  be  compressed,  to  arrest-  the  hemorrhage,  and  to  cause 
the  formation  of  a.  false  consecutive  aneurism,  which. can  afterwards 
be  cured,  by  tying  the  brachial  artery  above. 


230  TOPOGRAPHICAL  ANATOMY. 


CHAPTER      III. 


THIRD       PART       OF       THE       THORACIC       LIMB. 

This  portion  of  the  thoracic  limb  is  composed  of  the  proper  anti- 
brachial  region,  and  of  the  wrist,  which  unites  it  to  the  hand. 


I  .       ANTI-BRACHIAL       REGION. 

Properly  speaking,  the  fore-arm  is  the  third  section  of  the  thoracic 
limb ;  it  commences  below  the  elbow,  and  it  is  separated  artificially 
from  the  wrist  below,  by  a  circular  line,  drawn  one  finger's  breadth 
above  the  styloid  processes. 

The  form  of  the  fore-arm  is  conical ;  its  antero-posterior  diameter  is 
less  than  the  transverse ;  this  arrangement  seems  to  prepare  for  the 
flattening  of  the  hand. 

The  fore-arm  presents  two  faces,  an  anterior  or  palmar,  a  posterior 
or  dorsal,  and  two  edges,  a  radial  and  an  ulnar.  The  palmar  face  is 
generally  flattened  and  smooth ;  the  whiteness  of  its  surface  contrasts 
with  the  other  parts  of  the  region  ;  we  can  trace  there  the  sub-cutane- 
ous veins,  which  form  a  plexus,  all  the  branches  of  which  can  be 
followed  ;  finally,  above  and  in  the  centre,  we  remark  there  a  longitu- 
dinal depression  which  is  continuous  with  that  of  the  elbow,  and  which 
disappears  on  descending.  The  dorsal  face  is  convex  and  covered 
with  a  very  fine  down  ;  we  can  trace*  in  it  the  extensor  muscles  of  the 
fingers  when  they  are  contracted.  The  external  edge,  in  its  two  upper 
thirds,  is  rendered  very  convex  by  the  projecting  of  the  radialcs  extern! 
and  supinator  muscles  ;  it  is  slightly  depressed  below  this  point,  then, 
still  lower  down,  it  is  elevated  by  the  oblique  prominence  of  the  abduc- 
tor pollicis  magnus  and  extensor  pollicis  brevis  muscles.  The  internal 
edge  is  convex  above,  less  so,  however,  than  the  preceding ;  it  is  strait 
below. 

Structure* — 1.  Elements.  The  skeleton  of  the  fore-arm  is  formed 
by  the  central  or  thin  and  compact  portion  of  the  radius  and  ulna ; 
these  two  bones  are  united  by  the  inter-osseous  ligament,  which  is  defi- 
cient above,  and  which  presents  here  and  there  some  vascular  open- 
ings. The  muscles  should  be  distinguished  into  anterior,  posterior, 


ANTI-BRACHIAL  REGION.  281 

and  external,  some  of  which  project  out  of  the  inter-osseous  space,  and 
others  are  in  a  measure  contained  in  it :  among  the  anterior  muscles, 
two  only,  the  pronators,  terminate  in  the  fore-arm,  the  others  proceed 
downward.  .We  will  remark  that  the  direction  of  the  two  prona'tor 
muscles  is  oblique  or  transverse,  from  the  ulna  towards  the  radius. 
The  only  posterior  muscle  which  terminates  in  the  fore-arm  on  the 
ulna  is  the  anconeus  muscle ;  all  the  superficial  muscles,  except  this, 
are  very  long,  and  have  only  a  few  points,  of  insertion  in  the  bones  of 
this  region  ;  all  the  deep  muscles,  on  the  contrary,  are  short,  and  two 
of  them,  the  abductor  pollicis  longus,  and  the  extensor  pollicis  brevis, 
are  inserted  in  both  of  these  bones  at  .the  same  time.  The  muscles  of 
the  external  fasciculus  are  four  in  number,  of  which  the  two  supinators 
are  attached  by  their  lower  extremity  to  the  fore-arm,  while  the  other 
two  are  merely  situated  in  it.  The  antirb'rachial  apormirosis  forms  a 
common  envelope  for  all  this  mass  of  muscles  ;  it  also  constitutes  some 
secondary  sheaths  for  many  of  them.  These  sheaths  are  formed  by 
septa  which  go  from  the  inner  face  of  the  aponeurosis'toward  the  bones  ; 
they  are  stronger  superiorly  than  inferiorly,  and  are  firmer  superficially 
than  deeply  ;  finally,  all  proceed  from  the  tuberosities  of  the  humerus. 
In  order  to  form  them,  the  aponeurosis  is  attached  first  on  the  inner 
edge  of  the  ulna  arid  posterior  edge  of  the  radius,  and  thus  separates  the 
posterior  from  the  anterior  and  external  muscles ;  it  then  divides  the 
posterior  muscles  into  two  planes,  by  sending  a  layer  between  the  su- 
perficial and  the  deep  muscles,  thus  forming,  with  the  bones  and  the 
inter-osseous  ligament,  one  sheath  for  these  latter.  Each  of  the  deep 
muscles,  on  the  contrary,  has  a  distinct  sheath  ;  this  *  is  true  of  the 
anconeus,  the  extensor  carpi  ulnaris,  the  extensor  minimi  digiti,  and 
the  extensor  digitorum  communis  muscles.  All  the  external  muscles 
are  enveloped  in  the  same  sheath,  which  is  continuous  posteriorly  with 
that  of  the  common  extensor,  anteriorly  with  that  of  the  pronatOr  teres 
muscle,  and  is  strengthened  in  the  elbow  by  a  detached  expansion  of 
the  tendon  of  the  brachialis  internus  muscle  ;  anteriorly,  the  aponeu- 
rosis is  arranged  very  similarly  ;  it  divides  the  muscles  into  two  sec- 
tions by  sending  a  layer  before  the  flexor  communis  digitorum  sublimis, 
which  layer  forms  with  the  bones  and  the  inter-osseous  ligament  a  deep 
sheath  for  ttie  two  common  flexors,  and  for  that  of  the  thumb ;  the 
prOnator  quadratus  is  always  covered  by  a  special  layer,  which  is  in- 
serted on  the  opposite  edges  of  the  radius  and  ulna  ;*  next,  each  super- 
ficial muscle,  as  the  pronator  teres,' the  palmaris  longus  and  brevis,  and 
the  flexor  carpi  .ulnaris  muscle,  is  enveloped  in  a  very  thin  sheath. 

*In  some  animals,  particularly  in  cats,  this  fibrous  layer  of  the  pronator  quadratic,  is  con- 
siderably developed. 
36 


282  TOPOGRAPHICAL    ANATOMY. 

The  fore-arm  is  supplied  with  blood  by  four  large  arteries,  the 
radial,  the  ulnar,  and  the  inter-osseous  arteries.  The  first  two  are  the 
principal  arteries  ;  the  last  are  branches  of  the  ulnar  artery,  which  also 
gives  off  the  small  artery  of  the  median  nerve.  We  have  mentioned, 
when  speaking  of  the  elbow,  the  anastomoses  which  connect  the  arte- 
ries of  the  fore-arm,  and  those  of  the  arm  ;  in  the  fore-arm  also,  the 
posterior  and  anterior  arteries  are  united  by  the  perforating  branches 
of  the  inter-osseous  ligament.  The  anti-brachial  veins  are  deep  or  su- 
perficial ;  the  first  follow  exactly  the  course  of  the  arteries,  and  each 
artery  has  two  ;  the  superficial  are,  the  superficial  radial,  ulnar,  and 
the  median  veins.  These  veins  are  often  very  distinct  in  every  part ; 
sometimes  they  all  blend  below  in  the  posterior  and  anterior  plexuses, 
and  are  separated  only  at  the  upper  part  of  the  fore-arm  ;  the  radial 
and  the  ulnar  veins  generally  arise  posteriorly ;  they  then  turn  on  the 
edges  of  the  fore-arm  and  become  anterior.  The  superficial  lymphatic 
vessels  follow  the  course  of  these  veins,  and  pass  before  the  elbow  to 
open,  with  the  deep  lymphatics,  into  the  axillary  ganglions.  The 
nerves  are  superficial  and  deep ;  the  first  come  from  four  sources  ;  the 
two  cutaneous  nerves  and  some  cutaneous  branches  are  given  off  on 
the  inside  by  the  ulnar  nerve,  on  the  outside  by  the  radial  nerve  ;  the 
last  two  nerves,  with  the  median  nerve,  constitute  the  deep  nervous 
system  of  this  region.  Each  nerve  sends  off  some  filaments  to  the  ad- 
jacent parts  ;  the  radial,  also,  gives  off  posteriorly  a  remarkable  branch 
to  all  the  extensor  muscles.  The  sub-cutaneous  cellular  tissue  is  mo- 
derately loose  in  every  part;  the  sub-aponeurotic  tissue  presents 
nothing  special.  The  fat  of  the  fore-arm  is  almost  exclusively  sub- 
cutaneous ;  anteriorly,  the  skin  is  whiter,  finer,  and  less  downy,  than 
it  is  posteriorly. 

2.  Relations.  The  fore-arm  is  formed  by  some  organic  layers, 
which  are  more  numerous  anteriorly  and  on  the  outside,  than  'poste- 
riorly and  on  the  inside  ;  farther,  some  are  common  to  every  part, 
others  belong  specially  to  each  face.  The  common  layers  are  ;  the 
skin,  the  sub-cutaneous  cellulo-adipose  tissue,  in  which  the  superficial 
lymphatic  vessels,  nerves,  and  veins,  are  situated ;  finally,  the  super- 
ficial layer  of  the  aponeurosis.  The  deeper  layers  vary  singularly  for- 
ward, backward,  and  on  the  sides,  and  must  be  studied  successively 
in  these  different  parts  ;  first  anteriorly,  under  the  aponeurosis,  we 
find  on  the  outside  the  radial  artery  and  its  attendant  veins,  situated 
in  a  superficial  muscular  groove,  formed  by  the  approximation  of  the 
external  and  anterior  muscles.  These  vessels  follow  in  every  part  the 
course  of  an  imaginary  line,  drawn  from  the  centre  of  the  elbow  in 
front  of  the  styloid  process  of  the  radius ;  they  are  attended  on  the 
outside  by  the  radial  nerve,  sometimes  as  far  as  the  wrist,  sometimes 


ANTI-BRACHIAL  REGION.  283 

not  so  far,*  according  to  the  height  at  which  it  turns.  The  pronator 
teres  muscle,  the  tendon  of  which  only  is  situated  under  the  radial 
artery,  is  found  in  this  first  layer,  with  the  two  palmares  and  the  flexor 
carpi  ulnaris  muscle,  each  of  which  is  enveloped  by  a  special  fibrous 
sheath.  A  deep  aponeurosis  and  the  flexor  sublimis  muscle  form  the 
second  layer,  below  which  is  a  third,  formed  by  the  flexor  digitorum 
profundus,  and  the  flexor  pollicis  longus  muscles ;  but  between  this 
and  the  preceding  we  find,  in  the  centre,  the  median  nerve  and  its 
attendant  artery,  and  on  the  inside,  the  ulnar  vessels  and  nerves,  situ- 
ated, first  in  an  interstice,  formed  above  only  by  the  flexor  digitorum 
communis  and  profundus,  while  below,  on  the  contrary,  it  is  formed  by 
the  approximation  of  the  flexor  profundus  posteriorly,  the  flexor  carpi 
ulnaris  on  the  inside,  the  flexor  sublimis  and  the  deep  layer  of  the 
anti-brachial  aponeurosis,  on  the  outside  and  anteriorly.t  In  this 
interstice,  the  ulnar  artery  with  its  veins  is  directed,  first,  in  a  line 
drawn  from  the  centre  of  the  elbow  to  the  end  of  the  upper  third  of  the 
inner  edge  of  the  ulna.  In  the  first  part  of  its  course  it  is  very  deep, 
and  is  protected  anteriorly  by  all  the  superficial  muscles  of  the  anterior 
face  of  the  fore-arm  ;  lower  down,  its  direction  is  parallel  to  that  of  the 
radial  artery,  and  follows  the  course  of  a  line  supposed  to  be  drawn 
from  the  epitrochlea  to  the  styloid  process  of  the  radius ;  the  ulnar 
nerve  is  remote  from  the  artery  in  the  first  point,  but  below,  it  is  con- 
tiguous to  its  inner  part  and  continues  so.  Behind  the  flexor  digitorum 
profundus,  and  flexor  pollicis  longus  muscles,  appear  the  bones,  the 
inter- osseous  ligament,  and  the  anterior  inter-osseous  vessels  and  nerves, 
which  are  concealed  inferiorly  by  the  small  pronator  quadratus  mus- 
cle, which  is  also  enveloped  in  its  special  sheath.  Second,  posteriorly, 
under  the  aponeurosis.  we  find  a  first  layer  formed  by  the  extensor 
digitorum  communis,  the  extensor  minimi  digiti,  the  extensor  carpi 
ulnaris  and  anconeus  muscles,  all  of  which  are  surrounded  by  a  special 
sheath  ;  below,  is  a  second  layer,  formed  by  the  abductor  pollicis  major 
muscle,  the  two  extensors  of  the  thumb  and  the  indicator,  and  by  a 
part  of  the  supinator  brevis  muscle,  from  which  comes  the  dorsal 
branch  of  the  radial  nerve,  which  is  situated  with  the  posterior  inter- 
osseous  vessels,  between  the  two  layers  which  we  have  mentioned. 
All  these  parts  being  removed,  we  see  the  posterior  face  of  the  bones 
and  of  the  inter-osseous  ligament.  Third,  on  the  inside,  the  aponeurosis 

*  The  nerve  is  always  separated  from  the  radial  vessels  by  a  fibrous  layer  :  in  fact,  the 
nerve  is  situated  in  the  sheath  of  the  external  muscles  of  the  fore-arm,  the  vessels,  on  the 
contrary,  in  the  anterior  sheaths,  and  particularly  in  that  of  the  pronator  teres  above,  and  of 
the  flexors  below. 

fThe  ulnar  artery  is  always  situated  under  the  deep  layer  of  the  aponeurosis  of  the  fore- 
arm ;  hence,  to  reach  it  from  before  backward,  we  must  pass  through  two  fibrous  layers. 


TOPOGRAPHICAL  ANATOMY. 

adheres  directly  to  the  bone,  which  is  situated  alone  under  it  in  every 
part,  except  inferiorly,  where  we  find  the  dorsal  palmar  branch  of  the 
ulnar  nerve,  a  branch  which  turns  under  the  flexor  carpi  ulnaris 
muscle,  and  on  the  inner  edge  of  the  fore-arm,  at  a  height  which  varies. 
Fourth,  on  the  outside,  under  the  aponeurosis,  we  come  into  a  large  apo- 
neurotic  sheath,  in  which  are  situated  the  radial  nerve,  the  supmator 
longus,  the  radialis  externus  longior  and  brevior,  and  the  supinator 
brevis  muscles  ;•  above,  these  four  muscles  are  superimposed  from  with- 
out inward  in  the  preceding  order,  and  below  the  latter,  on  the  neck 
of  the  radius,  is  situated  the  dorsal  branch  of  the  radial  nerve.  In  the 
centre  of  this  edge  of  the  fore-arm  we  find,  on  the  outside  of  the  bone, 
only  the  supinator  longus  arid  the  radiales  externi  muscle's ;  lower 
down,  the  tendons  of  these  three  muscles,  are  crossed  obliquely  and 
superficially  by  the  abductor  pollicis  longus,  and  the  extensor  pollicis 
brevis  muscles,  which  come  from  the  posterior  face  of  the  fore-arm ; 
finally,  near  the  thumb,  these  last  two  muscles  and  the  supinator  longus 
cover  only  the  course  of  the  radial  nerve,  which  is  oblique  posteriorly. 
Development.  The  fore-arm  is  the  second  part  of  the  thoracic 
limb  which  is  formed  distinctly.  Before  the  period  of  puberty,  the 
sub-cutaneous  fat  is  so  abundant  anteriorly,  that  the  whole  region  has 
a  rounded  form. 

Varieties:  This  region  presents  numerous  anatomical  varieties. 
The  palmaris  brevis  muscle  is  often  deficient ;  the  flexor  pollicis  longus 
muscle  often  sends,  in  front  of  the  ulnar  artery,  a  fasciculus  toward 
the  epitrochlea  or  toward  the  coronoid  process,  &c.*  The  aponeurotic 
sheaths  are  sometimes  more  numerous  than  usual,  and  are  never 
deficient;  we  not  unfrequently  find  a  special  sheath  for  each  of  the 
external  muscles,  &c.  When  speaking  of  the  brachial  region,  we  have 
mentioned  the  varieties  in  the  origin  of  the  principal  arteries  in  this 
region,  in  consequence  of  the  premature  division  of  the  brachial  artery ; 
in  these  cases;  the  inter-osseous  artery  arises  sometimes  from  the  radial, 
sometimes  from  the  ulnar,  and.  even  from  the  brachial  artery.  Some- 
times the  ulnar  artery  does  not  occupy,  superiorly,  its  normal  deep 
position;  we  have' seen  this  variety  several  times  in  the  following 
degrees  :  first,  as.  in  Plate  VII.,  a  very  small  twig  is.  detached  from 
the  brachial  artery,  and  may  pass  on  'the  fasciculus  of  .the  epitro- 
chlear  muscles,  and  after  passing  a  short  distance,  penetrate  into  the 
ulnar  interstice,  to  anastomose  with  the  ulnar  artery,  which  has  its 
normal  arrangement ;  second,  sometimes  this  twig  is  as  •  large  as  the 
ulnar  artery,  which  may  then  be  considered  as  arising  by  two  roots,  a 
superficial  and  a  deep  root.  We  have  always  seen  the  first  pass  under 

*  We  consider  this  to  be  the  normal  arrangement  of  the  flexor  pollicis  longus  muscle,  but 
ention  it  as  a  variety,  only  to  conform  to  the  general  opinion. 


ANTI-BRACHIAL  REGION.  285 

the  aponeurosis  ;  Meckel  says  that  it  may  be  sub-cutaneous;  we  are 
more  inclined  to  believe  this,  as  the  rudimentary  twig,  which  .forms 
the  first  degree  of  this  variety,  frequently  divides  into  two  twigs,  the  one 
sub-cutaneous,  the  other  sub-aponeurotic,  as  is  seen  on  Plate  VII. ; 
third,  finally,  the  whole  ulnar  artery  may  pass  superficially,  and  be 
situated  in  its  interstice,  in  the  centr.e  of  the  fore-arm.  The  radial 
artery  often  gives  off  its  radio-palmar  branch  very  early ;  then,  also,  it 
often  turns  very  soon  under  the  supinator  longus  muscle,  and  goes  to 
the  dorsal  face  of  the  fore-arm.  We  have  once  seen  the  small  artery 
of  the  median  nerve  continuous  with  the  brachial  artery  ;  the  radial 
and  ulnar  arteries  were  rudimentary,  and  contrasted  with  the  great 
size  of  the  first. 

In  the  female,  the  sub-cutaneous  fat  retains  in  the  .fore-arm  the 
characters  of  infancy.  •  .  . 

Uses.  The  forfe-arm  has  been  called,  and  very  justly,  the  handle 
of  the  hand,  manubrium  manus.  In  fact,  the  hand  is  constantly 
rotated  with  it,  sometimes  forward,  pronation,  sometimes  backward, 
supination  :  these  motions  are  favored  particularly  by  the  breadth  of 
the  inter-os'seous  space. 

Pathological  and  operative  deductions'.  The  fore-arm  may  be 
entirely  deficient,  and  the  hand  may  exist ;  in  this  case,  the  develop- 
ment is  simply  arrested.  In  an  individual  who  died  recently  at  the 
Hospital  St.  Antoine,  only  the  upper  extremity  of  the  fore-arm  existed ; 
there  was  no  scar  as  evidence  that  an  amputation  had  been  performed ; 
we  saw  only  .the  skeleton  ;  the  upper  extremity  of  the  two  bones  of 
the  fore-arm  could  be  easily  distinguished;  the  head  of  the  radius, 
however,  was  deformed.  In  fractures  of  the  fore-arm,  the  inter-osseous 
space  is  more  or  less  completely  effaced  by  the  converging  of  the  loose 
extremities  of  the  fragments  of  the  bones ;  this  converging  is  caused 
by  the  action  of  the  muscles  of  this  space.  If  we  examine  this  dis- 
placement, particularly  when  the  radius  is  fractured,  we  see  that  on 
account  of  the  mobility  of  this  bone  in  its  upper  and  lower  articula- 
tions, the  two  fragments  come  together  toward  the  ulna.  -When  the 
ulna,  on  the  contrary,  is  fractured,  the  inferior  fragment  alone  deviates 
toward  the  radius  ;  the  upper  is  too  immoveable  in  its  humeral  articu- 
lation to  follow  the  same  course.  In  these  fractures,  as  the  inter-osseous 
space  is  important,  and  it  is  impossible  to  unite  the  fragments  in  any 
other  manner,  we  must  crowd  the  anterior  and  posterior  masses  of 
muscles  between  the  bones,  which  are  thus  pressed  from  within  out- 
ward, following  a  direction  opposite  to  the. action  of  the  displacing 
powers  ;  in  order  to  this,  we  must  make  the  antero-posterior  diameter  of 
the  fore-arm  larger  than  the  transverse,  by  means  of  pyramids  of  com- 
presses placed  in  this  direction.  It  is  easy  to  tie  the  radial  and  ulnar 


286  TOPOGRAPHICAL  ANATOMY. 

arteries  in  wounds,  if  we  cut  upon  the  course  of  the  lines  mentioned  : 
the  radial  artery  must  be  raised  from  without  inward,  and  the  ulnar 
artery  in  the  opposite  direction,  to  avoid  their  attendant  nerves.  The 
radial  artery  may  be  tied  in  every  part,  but  the  ulnar  artery  cannot  be 
tied,  in  its  upper  fourth,  without  great  trouble.  Where  one  of  these 
arteries  is  affected  with  aneurism,  on  account  of  the  large  anastomoses 
situated  in  the  hand,  we  must  tie  it  above  and  below  the  tumor,  or 
rather  we  must  place  one  ligature  on  the  brachial  artery.  The  fore- 
arm may  be  amputated  at  any  part ;  most  of  the  vessels  to  be  tied  are 
situated  in  the  anterior  part  of  the  stump,  or  in  the  anterior  flap ;  they 
are,  the  radial,  the  ulnar,  and  the  anterior  inter-osseous  arteries ;  the 
posterior  inter-osseous  artery  is  the  only  one  from  which  hemorrhage 
comes  posteriorly.  Union  by  the  first  intention,  after  this  operation, 
seems  to  us  less  suitable  than  when  the  arm  is  operated  upon,  for  two 
reasons  :  first,  on  account  of  the  great  number  of  tendons  which  form 
the  stump,  particularly  at  the  lower  part ;  second,  on  account  of  the 
very  strong  fibrous  sheaths,  which  surround  the  muscles ;  they  form 
canals,  and  are  always  ready  to  receive  the  pus  or  blood  which  are 
necessarily  effused  under  the  wound,  in  parts  where  the  ligatures  are 
situated ;  hence,  abscesses  are  formed,  which  interrupt  the  progress  of 
nature  in  cicatrization.  When  wounds  of  the  upper  and  external  part 
of  this  region  penetrate  to  the  bone,  they  are  necessarily  complicated 
with  the  injury  of  the  radial  nerve,  and  consequently  with  the  paralysis 
of  the  posterior  muscles  of  the  fore-arm,  the  extensors  of  the  hand  and 
fingers.  This  accident  is  also  attended  with  the  flexed  position  of 
these  parts,  which  obey  the  unequal  action  of  their  flexor  muscles. 


2.        REGION       OF       THE       WRIST. 

The  wrist  is  the  point  where  the  fore-arm  unites  with  the  hand  ; 
this  region  commences  above,  where  the  fore-arm  terminates,  and  is 
bounded  below  and  forward  by  a  curved  line,  which  corresponds  to 
the  pisiform  bone  on  one  side,  but  it  is  more  depressed  on  the  outside ; 
finally,  this  line,  if  continued,  will  terminate  the  lower  boundary. 

The  wrist  is  flat,  like  the  fore-arm  ;  its  transverse  diameter  is  more 
extensive  than  the  antero-posterior. 

This  region  presents  two  faces ;  the  anterior  or  palmar  face,  is  flat ; 
we  distinguish  there  some  blueish  lines,  which  anastomose  in  a  plexus, 
and  an  elongated  prominence ;  the  first  are  the  sub-cutaneous  veins, 
the  second  marks  externally  the  fasciculus  of  the  extensor  tendons ; 
two  transverse  folds  also  exist  in  the  wrist ;  they  are  caused  by  the 
flexion  of  this  part ;  the  pulsations  of  the  radial  artery  may  be  felt 


REGION  OF  THE  WRIST.  287 

there  above  on  the  radius  ;  this  is  also  the  place  selected  for  counting 
the  pulses.  The  posterior  or  dorsal  face  is  convex;  we  see. there, 
particularly  near  its  edges,  the  very  marked  prominences  of  the  veins  ; 
in  extension  only,  certain  tendons  are  very  much  marked,  and  we 
distinguish  particularly,  that  of  the  extensor  pollicis  longus,  which 
descends  obliquely  on  the  outside  ;  finally,  the  head  of  the  ulna  also 
forms  on  the  inside  and  backward  a  remarkable  eminence.  Of  the 
two  edges  which  separate  these  faces,  one  is  external  or  radial,  the 
other  is  internal  or  ulnar  ;  the  first  presents  above  a  convexity,  which 
belongs  to  the  inferior  and  enlarged  part  of  the  radius  ;  while  below, 
in  the  abduction  and  extension  of  the  thumb,  we  remark  there  an 
oblong  depression,  at  the  base  of  which  the  pulsations  of  the  radial 
artery  may  easily  be  perceived  ;  the  lines  which  circumscribe  this 
depression  belong  on  the  outside  to  the  tendons  of  the  great  abductor 
and  short  extensor  of  the  thumb  ;  on  the  inside,  to  its  great  extensor. 
The  second  edge  of  the  wrist  is  concave ;  it  is  the  base  of  the  angle, 
formed  by  the  union  of  the  inner  edges  of  the  hand  and  fore-arm  ;  we 
easily  feel  there  the  styloid  process  of  the  ulna. 

Structure. —  1.  Elements.     The   radio-carpal   and  inferior   radio- 
cubital  articulations  form  the  centre  of  this  region  ;  the  first  is  consti- 
tuted on  one  side  by  the  two  bones  of  the  fore-arm,  particularly  the 
radius,  and  on  the  other,  by  the  first  range  of  the  carpus,  except  the 
pisiform  bone ;  it  is  strengthened  by  four  ligaments,  which  are  not 
very  compact.     The  bones  of  the  fore-arm  contribute  to  form  this 
articulation  by  a  cavity  ;  the  bones  of  the  carpus  unite  and  form,  on 
the  contrary,  a  convex  surface  ;  on  the  whole,  the  line  of  the  articula- 
tion describes,  from  the  styloid  process  of  the  radius  to  that  of  the 
ulna,  a  slight  curve,  convex  superiorly.     The  second  articulation  is 
formed  simply  by  the  head  of  the  ulna  and  the  sigmoid  cavity  of  the 
radius  ;  it  is  kept  in  place  by  a  fibro-cartilaginous  layer,  which  is  often 
imperfect.     We  find  here  the  tendons  of  a  great  many  muscles ;  ante- 
riorly, are  situated  those  of  the  flexor  digitorum  communis,  the  flexor 
pollicis  longus,  the  flexor  carpi  ulnaris,  and  of  the  palmaris  longus  and 
brevis  muscles  ;  posteriorly,  those  of  the  extensor  digitorum  communis, 
the  extensor  carpi  ulnaris,  and  of  the  radiales  externi  muscles.     The 
portion  of  the  aponeurosis  which  surrounds  this  region  is  continued 
on  the  hand  and  fore-arm ;  it  is  very  strong,  particularly  posteriorly, 
where  its  transverse  fibres  are  very  visible,  and  constitute  the  posterior 
annular  ligament  of  the  carpus.     Its  internal  face  adheres  intimately 
to  the  external  and  internal  edges  of  the  radius  and  ulna,  and  sends 
some  prolongations,  which  partially  surround  the  tendons,  especially 
those  of  the  extensors,  forming  for  them,  with  the  bones,  some  osseo- 
fibrous  sheaths,   where  some   very  moist  synovial  membranes  are 


288  TOPOGRAPHICAL    ANATOMY. 

situated;  these -sheaths 'are  very  numerous  posteriorly;  and  they  there 
form  one  which  is  common  to  the  two  radiales  externi  muscles  *  ano- 
ther, which  is  oblique,  and  contains  the  tendon  of  the  extensor  pollicis 
longus ;  a  third,  which  belongs  to  the  tendons  of  the  extensor  com- 
munis  and  the  extensor  indicis  proprius  muscle ;  a  fourth,  for  the 
extensor  minimi  digiti  muscle :  the  latter  is  entirely  fibrous,  and  cor- 
responds to  the  space  between  the  radius  and  ulna ;  on  the  outside, 
the  tendons  of  the  extensor  brevis  and  of  the  abductor  pollicis  longus 
muscle  have  a  common  sheath,  and  the  extensor  carpi  ulnaris,  on  the 
inside,  possesses  a  special  sheath.  The  radial  and  ulnar  arteries,  are 
the  principal  arteries  of  this  region  ;  they  pass  through  it,  and  give  off 
in  it  some  twigs.  At  the  wrist,  the  radial  artery  divides  into  two 
branches ;  one  the  radio-palmar,  and  the  other  the  dorsal,  which  turns 
on  the  outside,  and  which  is  regarded  as  the  continuation  of  the  prin- 
cipal trunk.  The  ulnar  artery,  also,  sends  on  the  back  of  the  wrist 
a  branch  which  is  very,  small,  and  which  cannot  therefore  be  considered 
as  the  continuation  of  the  trunk.  The  nutritious  arteries  of  the  wrist 
form  two  plexuses,  by  which  the  two  principal  trunks  are  united  ;  one 
of  these  anastomotic  plexuses  is  anterior,  and  extends  along  the  lower 
edge  of  the  pronator  quadratus  muscle ;  the  other  is  posterior,  and  is 
formed  by  the  dorsal  artery  of  the  carpus,  and  the  dorsal  twig  of  the 
iilnar  artery ;  the  anterior  inter-osseous  artery  of  the  fore-arm  termi- 
nates in  both  of  these  arches,  which  thus  form  around  the  wrist  a 
very  remarkable  vascular  bracelet.  The  deep  veins  attend  the  arteries, 
and  are  always  in  pairs  ;  the  superficial  form  a  plexus,  the  branches 
of.  which  are  .larger  on  the  back  than  anteriorly  :  here  we  find  the 
origins  of  the  median  vein  of  the  fore-arm,  .there  those  of  the  superficial 
radial  and  ulnar  veins.  The  lymphatic  vessels  of  the  wrist  present 
nothing  peculiar ;  those  of  the  outside  go  into  a  small  ganglion,  placed 
on  the  back  of  the  wrist,  and  termed  the  supra-carpal.  The  nerves 
are  deep  or  superficial ;  the.  first  are  trunks  of  the  median  and  ulnar 
nerves,  which  only  pass  through  this  point ;  the  second  are  the  radial 
nerve  and  the  dorsal  twig  of  the  ulnar  nerve,  posteriorly;  anteriorly, 
and  on  the  sides,  the  cutaneous  nerves  of  the  fore-arm.  The  cellular 
tissue  of  the  wrist  is  loose  posteriorly ;  it  is  more  dense  anteriorly  ;  but 
..  ittle  fat  exists  there ;  the  skin  is  finer  and  smoother  anteriorly  than 
posteriorly. 

2.  Relations.  The  wrist  is  covered  with  the  skin,  which  is  more 
adherent  anteriorly  than  posteriorly ;  under  it  we  find,  in  the  sub-cuta- 
neous tissue,  the  superficial  lymphatics  and  veins  ;  anteriorly,  the  end 
of  the  cutaneous  nerves  of  the  fore-arm  ;  posteriorly,  and  on  the  sides, 
the  .end  of  the  radial  nerve,  that  .of  its  cutaneous  twig  of  the  fore-arm, 
and  the  dorsal  branch  of  the  ulnar  nerve.  Finally,  we  find  more 


REGION  OF  THE  WRIST.  289 

deeply  the  aponeurosis,  below  which  the  relations  vary  anteriorly, 
posteriorly,  and  on  the  sides.  Anteriorly,  the  radial  artery  apd  the 
radio-palmar  artery,  which  is  continuous  with  it ;  the  tendons  of  the 
two  palmares  and  of  the  flexor  carpi  ulnaris  appear  first ;  under  them, 
those  of  the  flexor  digitorum  communis  sublimis,  which  conceal  the 
median  nerve  and  its  artery ;  then  the  flexor  profundus  and  the  flexor 
pollicis  proprius  ;  next  the  anterior  arterial  plexus  and  the  articula- 
tion. On  this  face  and  near  the  inner  edge  of  the  region,  the  tendon 
of  the  flexor  carpi  ulnaris  on  the  inside,  that  of  the  flexor  digitorum 
communis  on  the  outside,  the  flexor  profundus  and  the  pronator  quad- 
ratus  posteriorly, form  an  interstice,  where  the  ulnar  vessels  are  situated, 
to  the  inside  of  which  the  ulnar  nerve  is  contiguous.  At  the  posterior 
part  of  the  wrist  we  find,  on  the  same  plane,  all  the  tendinous  sheaths 
and  their  tendons  in  the  order  mentioned  above ;  that  of  the  extensor 
pollicis  longus  crosses  below  and  superficially  the  tendons  of  the  ra- 
diales  externi  muscles ;  finally,  the  end  of  the  inter-osseous  artery 
always  passes  through  the  sheath  of  the  extensor  digitorum  communis 
muscle.  Under  the  aponeurosis  we  always  find,  on  the  outside,  the 
united  tendons  of  the  long  abductor  and  short  extensor  of  the  thumb ; 
below  the  artery,  the  radial  nerve,  and  the  articulation ;  on  the  inside, 
on  the  contrary,  the  extensor  carpi  ulnaris,  the  dorsal  branch  of  the 
ulnar  nerve,  and  also  the  articulation. 

Development.  Until  the  age  of  eighteen  years  the  thumb  presents 
but  a  slight  degree  of  resistance,  because  the  lower  epiphyses  of  the 
radius  and  ulna  are  not  fused  with  the  bones. 

Varieties,  This  region  is  subject  to  numerous  varieties.  We  have 
seen  there  one  large  artery,  following  the  direction  of  the  median 
nerve,  the  radial  and  ulnar  arteries  being  rudimentary.  The  radial 
artery  also  often  divides  before  coming  to  this  region.  In  these  cases, 
sometimes  the  two  branches  do  not  separate  as  in  the  normal  state, 
sometimes  the  dorsal,  which  may  be  considered  as  the  trunk  of  the 
artery,  turns  prematurely,  and  the  pulsations  which  are  felt  in  the 
usual  place  are  those  of  the  radio-palmar  twig,  and  not  those  of  the 
trunk  of  the  radial  artery. 

Uses.  The  region  of  the  wrist  presents  motions  of  two  kinds ;  some 
belong  to  the  radio-carpal  articulation  and  are  very  extensive,  being 
performed  in  every  direction  ;  others  occur  in  the  radio-cubital  articu- 
lation, and  are  confined  to  the  rotation  of  the  radius  on  the  ulna,  the 
ulna  being  fixed.  In  these  motions,  the  radius  and  the  hand  are  inti- 
mately united,  and  always  rotate  together ;  their  position  varies,  and 
thus  causes  the  states  of  supination  and  pronation.  This  latter,  pro- 
duced by  the  rotatory  motions  forward,  which  are  the  most  extensive, 
may  be  carried  very  far. 

37 


ayo  TOPOGRAPHICAL    ANATOMY. 

Pathological  and  operative  deductions.  Anterior  wounds  of  the 
wrist  are  the  most  serious.  Like  those  which  affect  the  other  parts  of 
this  region,  they  may  be  complicated  with  the  division  of  certain  ten- 
dons, and  also  some  large  nervous  and  vascular  trunks  may  be  divided : 
the  radial  artery  also  may  be  cut  in  wounds  made  outward  and  a  little 
backward.  In  distinguishing  fractures  of  the  radius,  we  take  advan- 
tage of  the  fact  that  this,  bone  must  rotate  with  the  hand;  we  rotate 
the  hand  and  also  the  lower  fragment  of  the  fracture,  and  thus  we  ob- 
tain the  crepitation.  Dislocations  of  the  wrist  are  rare  when  the  de- 
velopment is  perfect ;  sprains  of  its  principal  articulation  are  much 
more  common.  :The  small  head  of  the  ulna  may  be  dislocated  on  the 
radius,  which  generally  takes  place  posteriorly,  on  account  of  the  ex- 
tent of  the  motions.  Hydarthrosis  of  the  wrist  forms  a  tumor  which 
first  raises  the  layer  of  the  tendons,  and  afterwards  projects  above  their 
sides.  Dropsy  of  the  synovial  sheaths  of  the  wrist  constitutes  gang- 
lions, which  are  frequently  seen  posteriorly ;  a  tumor  of  this  kind 
sometimes  forms  anteriorly,  in  the  sheath  of  the  flexor  tendons  :  it  then 
glides  under  the  anterior  annular  ligament  of  the  carpus  into  the  hand, 
and  seems  strangulated,  before  the  wrist.  It  is  dangerous  to  open 
these  tumors,  on  account  of  the  inflammation  which  is  caused,-and  the 
adhesions  which  follow  arjd  necessarily  impede  the  motions  of  the  part  : 
this  operation,  also,  when  imprudently  performed,  may  cause  caries  of 
the  carpus.  In  the  resection  of  the  wrist,  we  must  follow  the  advice 
of  Roux,  and  operate  on  the  lateral  and  posterior  parts  of  the  region : 
in  this  manner,  we  divide  but  very  few  vessels  and  tendons.  In  am- 
putating the  wrist  at  the  joint  we  must  make  an  anterior  flap,  which 
is  more  vascular  and  better  nourished  than  that  which  can  -be  made 
posteriorly  :  in  order  to  disarticulate  it  rapidly,  we  may  place  the  knife 
under  the  styloid  process  of  the  radius-,  'and  then  make  the.  incision  ac- 
cording to  the  course  of  the  articular,  curve.  This  operation  has -suc- 
ceeded several  times,  but  sometimes  the  tendinous  sheaths,  which 
remain  open,  carry  the  pus  to  the  fore-arm;  it  always  requires  the 
ligature  of  the  radial,  ulnar,  an4  end  of  the  inter-osseous  arteries/ 


HAND.  S91 


CHAPTER      IV. 


OF       THE       HAND. 

Considered  generally,  the  hand*  may  be  defined,. the  loose  extremity 
of  a  limb  divided  into  fingers,  one  of  which  may  be  opposed  to  the 
others. 

The  fourth  section  of  the  thoracic  limbs  in  man  is  a  species  of  the 
hand,  for  it  presents  all  its  characters,  and  as  in  him  it  possesses  them 
exclusively,  man  is  termed  bimanous. 

In  man,  the  hand  is  remarkably  flat,  which  increases  its  surface  of 
touch ;  it  is  destitute  of  hairs  anteriorly,  and  is  concave  in  this  direc- 
tion ;  the  hairs  which,  it  presents  on  its  posterior  face,  form  only  a 
slight  down  ;  it  presents  two  edges,  a  radial. and  an  ulnar.  The  upper 
extremity  is  united  to  the  fore-arm  by  the  wrist,  from  .which  it  is  dis- 
tinguished anteriorly,  by  a  natural  line  already  mentioned.  The 
loose  extremity  is  divided  into  five  fingers,  which  will  be  described 
separately. 

The  texture  of  the  hand  seems  combined  to  render  it  very  sensible 
and  very  moveable  ;  its  upper  or  carpal  part  is  slightly  developed,  its 
digital  extremities,  on  the  contrary,  are  very  much  so ;  one  of  them 
is  detached  from  the  others. 

In  the  female,  the  hand  is  smaller ;  more  fat  is  found  on  its  dorsal 
face  than  in  the  male,  and  its  form  is  consequently  more  beautiful. 

The  uses  of  the  hand  are  numerous,  and  depend  on  its  sensibility 
and  mobility.  As  a  sensible  part,  it  is  the  most  perfect  organ  of  touch ; 
its  motions  also  serve  for  the  exercise  'of  this  faculty,  and  also  for 
taking  or  for  preparing  food  ;  among  the  motions  of  the  hand  there 
is  none  more  important  to  its  functions  than  that  of  opposition,  in 
which  the  thumb  and  its  metacarpal  bone  are  detached  from  the  other 
fingers  and  proceed  to  meet  them. 

*  The  loose  section  of  the  limbs  presents  in  animals  numerous  varieties,  in  respect  to  its 
uses  and  formation.  Considered  in  the  first  point  of  view,  this  part  serves  sometimes  for  a 
fin ;  sometimes  a  wing ;  sometimes  a  base  of  support,  a  foot ;  sometimes  it  becomes  an 
organ  of  prehension  and  of  touch,  a  hand.  In  respect  to  its  formation,  it  is  sometimes  simple, 
sometimes,  on  the  contrary,  it  is  divided  into  fingers,  of  which  there  are  nevermore  than  five. 
These  segments  may  be  situated  on  the  same  plane  and  fixed,  or  one  of  them,  which  is  de- 
tached from  the  rest,  may  be  more  moveable  and  capable  of  being  opposed  to  them  ;  the 
loose  part  of  a  limb,  modified  as  in  this  latter  case,  .is  a  hand.  Men  and  cpes  arc  the 
only  animals  provided  with  them. 


292  TOPOGRAPHICAL    ANATOMY. 

In  respect  to  its  functions,  and  also  its  structure,  the  hand  is  com- 
posed of  two  very  distinct  regions,  the  palmar  and  the  digital.  We 
will  examine  them  successively. 


1.        PALMAR        REGION. 

The  palm  of  the  hand  is  its  undivided  portion  of  which  it  forms 
more  than  the  upper  half.  It  presents  two  faces  ;  the  anterior  is  gene- 
rally concave  and  forms  the  hollow  of  the  hand :  this  face  is  bounded 
on  the  outside  and  inside  by  two  prominences  ;  the  external,  termed 
the  thenar,  belongs  to  the  muscles  of  the  thumb,  the  internal,  termed 
the  hypo-thenar,  marks  externally  the  fasciculus  of  the  muscles  of  the 
little  finger.  Three  curved  grooves,  which  are  often  united  by  others 
which  are  smaller,  exist  on  the  anterior  face  of  the  hand ;  one  supe- 
rior, the  concavity  of  which  is  directed  upward  and  outward,  a  second, 
inferior,  the  arrangement  of  which  is  directly  opposite  ;  finally,  the 
central  is  almost  concentric  with  the  first ;  the  former  is  caused  by  the 
opposition  of  the  thumb ;  the  second,  by  the  forced  flexion  of  the  last 
four  fingers  ;  the  latter,  by  that  of  the  palm  of  the  hand.  Finally,  four 
eminences,  which  are  more  or  less  callous,  like  the  posterior  part  of 
the  hypo-thenar,  correspond  to  the  heads  of  the  last  four  metacarpal 
bones.  The  other  face  of  the  palm  of  the  hand,  the  posterior  or  dorsal 
face,  is  convex  ;  we  see  there  the  tendons  of  the  extensors  of  the  fingers, 
and  also  the  bluish  lines  of  the  superficial  veins,  and  on  the  outside, 
near  the  wrist,  we  can  feel  the  pulsations  of  the  radial  artery.  The 
external  or  radial  edge  is  continued  by  the  thumb,  it  is  convex  and  less 
extensive  than  the  internal,  which  has  the  same  general  form,  and  on 
which  we  feel,  above,  a  prominence  which  belongs  to  the  upper  ex- 
tremity of  the  fifth  metacarpal  bone. 

Structure.  —  1.  Elements.  The  skeleton  of  the  palm  of  the  hand 
is  formed  by  the  carpal  and  metacarpal  bones ;  the  whole  of  this 
skeleton  is  so  arranged,  that  it  forms  an  arch  concave  anteriorly,  which 
is  destined  to  protect  the  minutest  organs ;  the  joints  are  secured  by 
strong  ligaments,  and  represent  the  supports  of  this  palmar  arch ; 
among  these  attachments,  the  inferior  transverse  metacarpal  is  parti- 
cularly remarkable ;  it  embraces  only  the  heads  of  the  last  four  meta- 
carpal bones  ;  at  the  metacarpus,  the  bones  are  separated  by  the  inter- 
osseous  spaces.  The  muscles  of  the  palm  of  the  hand  are  intrinsic  or 
extrinsic  ;  the  latter  are  situated  on  all  the  faces  of  the  region,  and 
extend  there  from  the  fore-arm ;  they  are  the  common  extensor  of 
the  fingers,  the  special  extensors  of  the  little  finger,  of  the  index  finger, 
and  of  the  thumb,  the  extensor  carpi  ulnaris  and  the  radiales  extern! 


PALMAR  REGION.  295 

muscles,  on  the  posterior  face  ;  the  flexor  communis  sublimis  and  pro- 
fimdus,  the  flexor  pollicis  longus,  the  two  palmares,  and  the  flexor 
carpi  ulnaris,  on  the  anterior  face  ;  the  abductor  pollicis  longus,  on  the 
outside.  The  intrinsic  muscles  are  all  situated  anteriorly  or  in  the 
metacarpal  spaces ;  some  go  to  the  thumb,  and  form  the  prominence 
of  the  thenar  ;  they  are,  the  abductor  pollicis  brevis,  the  flexor  brevis, 
the  opponens  pollicis,  and  the  abductor ;  the  others  belong  to  the  emi- 
nence of  the  hypo-thenar  and  the  little  finger  ;  they  are,  the  palmaris 
brevis,  the  adductor  minimi  digiti,  the  flexor  brevis,  and  the  abductor 
minimi  digiti  ;  finally,  others  occupy  an  intermediate  point,  and  belong 
to  all  the  fingers,  except  the  thumb  ;  they  are,  the  lumbricales  and  the 
iriter-ossei  muscles,  the  position  of  which  is  indicated  by  their  name. 
The  two  faces  of  the  palmar  region  are  protected  by  an  aponeurosis, 
which  is  continuous  above  with  that  of  the  wrist,  and  terminates  be- 
low at  the  roots  of  the  fingers  ;  its  dorsal  portion  is  very  thin  and  is 
attached  to  the  extensor  tendons,  between  which  it  is  situated ;  its 
palmar  portion  is  very  resisting  in  the  centre,  but  is  feeble  on  the  pro- 
minences of  the  thenar  and  hypo-thenar  ;  in  the  first  point,  it  receives 
the  expansion  of  the  tendon  of  the  palmaris  longus  muscle,  and  thence 
goes  radiating  to  the  metacarpo-phalangean  extremity  of  the  palm  of 
the  hand,  and  then  divides  into  four  slips,  which  terminate  separately 
on  the  head  of  the  last  four  metacarpal  bones,  which  are  included  be- 
tween their  bifurcation  ;  the  slips  of  this  aponeurosis  are  united  below 
by  some  transverse  fibres,  which  renders  this  part  remarkably  strong ; 
the  anterior  annular  ligament  of  the  carpus  is  attached  to  it  but  slightly; 
.  it  forms  with  the  carpus,  an  osseo-fibrous  sheath  for  the  tendons  of  the 
flexor  muscles,  and  also  protects  the  other  parts  of  the  hand  by  its 
strong  resistance.  Another  palmar  aponeurosis,  which  is  not  described 
by  authors,  is  extended  deeply  on  the  inter-ossei  muscles  and  the  deep 
palmar  arch  of  the  hand,  and  is  continuous  with  the  inferior  trans- 
verse metacarpal  ligament.  The  arteries  of  the  hand  terminate  the 
arterial  system  of  the  thoracic  limb ;  they  arise  from  the  ulnar  and 
radial  arteries  on  the  sides,  from  the  inter-osseous  artery  in  the  middle, 
and  from  the  artery  of  the  median  nerve  ;  these  last  two,  in  the  normal 
state,  are  not  very  important.  The  arterial  system  of  the  palm  of  the 
hand  is  formed  by  two  arches,  one  superficial,  the  cubito-radial.  the 
other  deep,  the  radio-palmar,  the  first  is  formed  particularly  by  the 
ulnar  artery,  and  the  second  by  the  radial ;  they  are  situated  anteriorly, 
and  are  formed  by  broad  anastomoses  of  the  radial  and  ulnar  arteries  ; 
the  radial  artery  deviates  towards  the  back  of  the  palmar  region  of  the 
hand,  in  order  to  distribute  to  it  some  twigs  which  are  necessary  to  its 
nutrition  ;  it  then  returns  immediately  to  the  inner  face  of  the  hand,  to 
which  it  is  distributed.  The  veins  of  the  palm  of  the  hand  do  not 


294  TOPOGRAPHICAL  ANATOMY. 

attend  the  arteries  ;  there  are,  however,  two  large  radial  veins,  which 
form  a  deep  double  arch ;  but  in  the  course  of  the  superficial  arterial 
arch,  we  find  hardly  one  rudimentary  vein.  The  veins  of  this  region 
are  situated  principally  on  its  back,  where  they  form  a  plexus,  the 
origin  of  the  superficial  ulnar  and  radial  veins.  The  lymphatic  ves- 
sels are  arranged  like  the  veins  ;  they  are  numerous  on  the  back  and 
under  the  skin,  and  but  few  exist  deeply  on  the  course  of  the  arteries. 
The  palmar  nerves  are  given  off  by  the  median,  the  ulnar,  the  radial, 
and  the  two  external  and  internal  cutaneous'  nerves  of  the  fore-arm  ; 
some  of 'these  nerves  are  cutaneous,  and  others  deep-seated.  The 'skin 
receives  some  filaments  from  the  two  cutaneous,  the  median,  the  ulnar, 
and  the  radial  nerve,  which  terminates  there  with  its  cutaneous  fila- 
ment of  the  arm.  The  trunks  of  the  median  and  ulnar  nerves  are  the 
only  deep-seated  nerves. 

The  cellular  tissue  of  the  palm  of  the  hand  is  loose,  and  slightly 
adipose,  posteriorly ;  it  is,  on  the  contrary,  very  compact  anteriorly ; 
it  contains  numerous  adipose  vesicles  at .  the  eminence  of  the  hypo- 
thenar,  and  at  the  heads  of  the  metacarpal  bones ;  in  these  different 
points,  also,  the  fat  is  situated  in  fibrous  canals,  one  extremity  of  which 
is  attached  to  the  skin,  the  other  to  the  aponeuroses  ;  these  canals  are 
rudimentary  in  man,  but  are  much  more  developed  in  those  animals 
which  rest  in  standing  on  the  thoracic  limbs.  The  skin  of  the  anterior 
face  of  the  hand,  is  thicker  than  that  of  the  back ;  it  often  becomes 
callous  in  those  parts  which  are  constantly  exposed  to  pressure. 

2;  Relations.  .  The  relations  of  the  palm  of  the  hand,  in  order  to 
be  properly  understood,  must  be  examined  successively  on  its  two 
faces. 

1.  Anterior  face.  This  must  be  divided  into  three  secondary  sec- 
tions ;  that  of  the  thenar,  of  the  hypo-thenary  and  of  the  palm,  of  the 
hand. 

At  the  eminence  of  the  thenar,  we  find  successively,  a  fine  skin, 
which  is  not  callous ;  an  adipose  cellular  tissue,  in  which  is  a  plexus 
of  superficial  veins,  and  some  filaments  of  the  external  cutaneous,  and 
frequently  of  the  radial  nerve  ;  a  thin  aponeurotic  layer  ;  the  abductor 
pollicis  breyis  muscle,  through  which  the  radio-palmar  artery  passes 
above ;  the  opponens  pollicis,  and  a  fasciculus  of  the  flexor  brevis, 
which  muscles  are  separated  near  the  thumb,  by  the  external  collateral 
artery  of  this-  finger  ;  the  tendon  of  the  flexor  pollicis  longus  muscle ; 
the  second  fasciculus  of  the  flexor  pollicis  brevis  ;  the  first  metacarpal 
bone';  the  external  part  of  the  carpus ;  and  the  tendon  of  the  flexor 
carpi  radialis  muscle,  which  is  situated  in  the  groove  of  the  trapezium. 

At  the  hypo-thenar  eminence,  the  skin  is  thick  and  callous  above  : 
it  covers  a  dense  fibro-cellular  layer,  which  attaches  it  to  the  aponeu- 


PALMAR  REGION.  W 

rosis,  and  in  the  centre  of 'which  are  situated  three  or  four  fasciculi  ol 
the  palmarisbrevis  muscle,  some  filaments  of  the  internal  cutaneous  and 
ulnar  nerve,  the  internal  collateral  nerve  and  artery  of  the  little  finger ; 
more  deeply  is  situated,  a  fibrous  layer,  which  "is  stronger  than  that.oi 
the  thenar  eminence ;  then,  on  the  same  plane,  the  adductor  and  flexor 
brevis  minimi  digiti  muscles,  and  the  origin  of  the  superficial  palmar 
arch,  which  is-  adjacent  on  the  inside  to  the  ulnar  nerve ;  inferiorly, 
the  opponens  muscle,  through  which  the  deep  branch  of  the .  ulnar 
artery  and  of  the  nerve  passes  above,  and  finally,  the  fifth  metacarpal 
bone. 

In  the  centre  of  the  anterior  face,  the  skin  is  callous  above,  and  it 
rests  below  on  a  very  dense  cellule-fatty  layer,  in  which  ramifies  a 
filament  of  the  median  nerve,  and  by  which  it  is  united  to  the  most 
resisting  part  of  the  palmar  aponeurosis,  which -comes  next;  this 
aponeurosis  conceals  above,  the  anterior  .annular  ligament  of4  the 
carpus,  below,  the  superficial  palmar  arch,  and  the  trunks  which  come 
from'  it ;  farther  behind  this  fibrous  layer,  are  situated,  the  collateral 
nerves  of  the  fingers,  and  the  end  of  the  median  arid  ulnar  nerves,  the 
tendons  of  the  superficial  flexor  muscle,  then  those  of  the  deep  flexor, 
which  are  separated  by  the  lumbricales  muscles,  which  parts  are  united 
by  a  -very  loose  lamellar  tissue,  and  frequently  by  a  prolongation  of  the 
mucous  bursa  of  the  carpus  ;  below  this  fasciculus,  we  find  a  fibrous 
layer,  situated  on  the  deep  palmar  arch,  the  deep  branch  of  the  ulnar- 
nerve,  and  the  last  palmar  inter-ossei  muscles ;  finally,  on  the  outside, 
the  abductor  pollicis  muscle,  through  which  the  radial  vessels  pass, 
and  which  are  contiguous  to  the  first  two  inter-ossei -muscles,  being 
separated. from  them  by  an  interstice,  in  which  the  collateral  vessels 
of  the  thumb  and  index  finger  ramify. 

2.  Posterior  face.  The  relations  of  the  posterior  or  dorsal  face,  are 
very  simple, -and  are  formed  by  the  successive- super-position  of  the 
following  layers  :  the  skin,  which  is  fine  and  slightly  downy  ;  a  loose 
cellular  tissue,  which  presents  but  little  fat,  and  in  the  centre  of  which 
rarnify  many  superficial  veins  and  lymphatic  vessels, .  and  also  the 
radial  nerve,  the  .dorsal  branch  of  the  ulnar  nerve,  and  the  cutaneous 
brachial  filament  of  the  former  ;  the  dorsal  aponeurosis,  and  the  ex- 
tensor tendons  which  are  situated  on  the  same  plane ;  more  deeply, 
upward  and  outward,  the  tendons  of  .the  radiales  externi  muscles ; 
then  below  them,  the  radial  vessels,  the  dorsal  twigs  of  the  carpus  and 
metacarpus,  all  of  which  are  covered  by  the  tendons  of  the  preceding, 
muscles  ;  finally,  the  back  of  the  carpus,  the  metacarpus,  the  muscles 
which  fill  the  metacarpal  spaces,  and  the  arteries  which  pass  through 
them,  particularly  the  radial  artery,  to  establish,  anastomoses  between 
the  posterior  and  anterior  arterial  systems  of  the  palm  of  .the  hand. 


296  TOPOGRAPHICAL  ANATOMY. 

Uses.  The  palm  is  the  most  solid  part  of  the  hand ;  this  supports 
the  weight  of  the  body  in  some  rare  cases,  where  the  thoracic  limb 
serves  as  a  column  of  support,  or  to  repel  obstacles  ;  we  then  can  form 
an  idea  of  the  advantage  derived  by  the  position  of  the  vessels  and 
nerves  in  the  carpo-metacarpal  groove ;  they  are  also  protected  very 
perfectly  by  two  strong  ligaments,  the  annular  and  the  palmar  apo- 
neurosis,  which  prevent  in  every  direction  the  collapse  of  the  arch 
which  it  forms ;  the  external  form  of  the  palm  of  the  hand  enables  it 
to  hold  liquids,  which  may  be  kept  in  its  anterior  depression,  the  depth 
of  which  can  be  increased  by  the  contraction  of  the  muscles  of  the 
hypo-thenar,  and  particularly  by  the  palmaris  brevis,  which  contraction 
is  combined  with  the  opposite  motion  of  the  first  metacarpal  muscle. 

Pathological  and  operative  deductions.  Wounds  of  the  palm  of 
the  hand  are  not  very  serious,  when  made  posteriorly  and  externally, 
provided  the  radial  artery  be  uninjured;  but  those  of  the  anterior 
face,  especially  if  made  by  a  pricking  instrument,  are  extremely  severe, 
on  account  of  the  texture  of  this  part ;  numerous  vessels  and  nerves 
also,  may  there  be  affected,  as  we  have  seen  ;  and  farther,  the  intimate 
adhesion  of  the  skin  to  the  palmar  aponeurosis,  and  the  very  great 
resistance  of  the  latter,  may  prevent,  in  superficial  or  deep  wounds,  the 
swelling  or  inflammation  from  taking  place  freely,  and  consequently 
a  strangulation  may  be  produced,  which  may  cause  severe  pain, 
and  mortification  of  the  deep  parts.  Wounds  under  the  aponeurosis, 
even  if  very  simple,  often  cause  the  tendons  to  adhere  to  each 
other,  and  impede  the  motions  ;  in  the  most  severe  cases,  pus  forms  in 
the  sheaths  of  the  tendons,  and  if  not  soon  discharged,  it  burrows 
under  the  annular  ligament  to  the  wrist,  and  even  to  the  fore-arm. 
We  often  find  pus  in  the  palm  of  the  hand,  although  no  primitive 
affection  of  this  exists ;  it  comes  there  from  the  sheaths  of  the  fingers, 
the  mucous  bursae  of  which  often  extend  into  this  region.  The  skin 
of  the  palm  of  the  hand,  by  its  dryness  or  moisture,  by  its  heat  or  cold, 
often  presents  pathologists  with  remote  but  constant  symptoms  of  deep 
diseases. 

The  laxity  of  the  dorsal  cellular  tissue  of  the  palm  of  the  hand, 
explains  the  facility  with  which  it  is  infiltrated,  in  diseases  of  the 
thoracic  limbs,  while  the  contrary  is  true  of  the  anterior  face.  Diffe- 
rent operations  may  be  performed  on  the  palm  of  the  hand  ;  a  part  of 
it  may  be  amputated  in  the  articulation  of  the  carpus  with  the  last 
four  metacarpal  bones,  as  has  been  proposed  by  'Maingault.  This 
operation  is  successful  on  the  cadaver,  and  the  disarticulation  is  per- 
formed rapidly,  if  we  take  as  a  guide  the  prominence  of  the  outer  edge 
of  the  hand  which  has  been  mentioned.  It  has  also  been  proposed  to 
amputate  a  part  of  the  hand  in  the  articulation  of  the  two  ranges  of 


DIGITAL  REGION.  *97 

the  carpus ;  the  extirpation  of  the  whole  hand  is  preferable.  The 
first  and  fifth  metacarpal  bones  may  easily  be  extirpated,  with  the 
finger  which  they  support ;  the  latter  operation  is  the  more  difficult, 
on  account  of  its  double  articulation  with  the  carpus  and  the  fourth 
metacarpal  bone.  Roux  was  the  first  to  remove  a  metacarpal  bone, 
preserving  the  corresponding  finger ;  he  performed  this  operation 
successfully  on  the  left  thumb  of  a  tailor.  The  radial  artery  may  be 
easily  tied  on  the  back  of  the  carpus,  and  the  ulnar  artery  on  the 
anterior  part  of  it,  if  necessary,  as  is  proved  by  the  position  of  these 
vessels. 

The  fingers  are  often  flexed,  on  the  palm  of  the  hand,  by  old  cica- 
trices, which  are  frequently  caused  by  burns  improperly  treated  ;  they 
must  be  cut  to  their  base,  taking  care,  however,  to  avoid  the  tendon, 
the  tension  of  which  varies  ;  the  finger  must  afterwards  be  flexed,  if  it 
was  previously  extended  ori .  the  back  of  the  palm  of  the  hand,  and 
must  be  extended,  if  its  direction  was  that  of  flexion  ;  finally,  it  must 
not  be  left  to  itself  until,  the  cicatrization  is  completed.  By  this  mode 
of  treatment,  the  finger  recovers  all  its  motions. 


2  ..     DIGITAL      REGION. 

The  fingers  are  the  terminating  appendages  of  the  hand.  Of  these, 
there  are  five,  separated  by  intervals  more  or  less  deep,  but  which 
never  extend  the  whole  length  of  the  fingers.  They  are  termed  by 
different  names :  the  first  is  the  thumb,  the  second  the  index,  the  third 
the  middle,  the  fourth  the  ring,  and  the  fifth,  the  auricular  or  little 
finger.  The  length  of  the  fingers  varies ;  the  longest  is  the  middle 
finger,  next  comes  the  ring  finger,  then  the  index  finger,  the  thumb, 
and  the  little  finger.  They  vary  •  much,  also,  in  size  :  the  thumb  is 
the  largest;  next  come,  successively,  the  middle,  the  index;  the  ring, 
and  the  little  finger. 

The  direction  of  the  fingers  is  varied  by  their  motions;  they  are 
Situated  on  the  same  plane,  except  the  thumb,  which  is  the  most,  ante- 
rior, and  can  become  still  more  so  in  certain  cases.  This  arrangement 
of  the  thumb,  on  which,  with  other  circumstances,  depends  its  opposi- 
tion, forms  the  special  character  of  the  hand.  The  fingers  are  slightly 
flattened  from  before  backward  ;  considered  externally,  we  distinguish 
in  them  four  convex  faces,  and  two  extremities.  The  anterior  face  is 
the  most  depressed :  it  is  remarkable  for  some  transverse  folds,  which 
are  very  prominent  in  flexion  ;  these  folds  .correspond  more  or  less 
exactly  to  the  articulations,  and  it  is  important  to  determine  them  with 
precision.  The  highest,  which  is  often  double,  extends  six  lines  below 

33 


298  TOPOGRAPHICAL  ANATOMY. 

the  metacarpo-phalangean  articulation ;  the  middle,  which  is  generally 
double  also,  corresponds  exactly  with  the  first  phalangean  articulation. 
The  third  is  generally  single,  and  is  situated  a  line  and  a  half  above 
the  union  of  the  second  and  third  phalanges.     The  middle  groove  is 
deficient  in  the  thumb,  on  which,  however,  we  find  three  folds  ante- 
riorly ;  but  the  highest  belongs  specially  to  this  finger,  and  corresponds 
exactly  to  its  metacarpal  articulation.     The  dorsal  face  of  the  fingers 
is  entirely  rounded  ;  we  see  there,  as  in  the  anterior  face,  some  grooves, 
which  correspond  more  exactly  than  the  preceding  to  the  articulations  ; 
in  flexion  of  the  fingers,  three  angular  prominences  appear  on  this 
face,  the  summit  of  which  does  not  correspond  to  the  articulations,  but 
is  situated  in  every  part  one  line  above.     The  lateral  faces  are  nearly 
plane,  and  present  only  the  continuity  of  the  anterior  and  posterior 
grooves.     The  upper  or  palmar  extremity  is  attached:  the  last  four 
fingers  are  united  at  its  level  by  a  membrane,  a  prolongation  of.  the 
skin  of  the  palm  of  the  hand ;  it  is  a  remnant  of  that  which  unites 
them  as  far  as  the  nail,  in  the  fetus.     This  inter-digital  membrane 
forms  the  base  of  the  inter-digital  angle,  which  is  six  lines  distant 
from  the  level  of  the  metacarpo-phalangean  articulation,  whence  it 
follows  that  the  fingers  are  blended  above  with  the  palm  of  the  hand. 
The  thumb  is  entirely  loose  at  its  base ;  the  base  of  the  groove,  which 
separates  it  from  the  index  finger,  is  situated  at  its  metacarpal  articu- 
lation.    The  loose  or  ungual  extremities  of  all  the  fingers  are  rounded, 
and  present  an  elastic  prominence,  remarkable  for  the  arrangement 
of  the  papillary  eminences  of  the  skin,  which  there  circumscribe  some 
concentric  ellipses  ;  posteriorly,  we  find  the  nail,  a  quadrilateral  layer 
of  horny  substance,  produced  by  the  skin,  and  situated  in  a  very 
marked  groove  of  this  membrane,  the  matrix  of  the  nail.     The  base 
of  this  groove,  which  is  seen  very  distinctly  in  Plate  VIII.,  Figure 
3,  is  formed  by  the  place  where  the  derma  of  the  skin  is  reflected, 
to  go  from  the  superficial  to  the  attached  face  of  the  nail ;  in  this 
groove,  the  latter  is  very  thin  and  cutting. 

Structure.  —  1.  Elements.  The  structure  of  the  fingers  is  very 
simple,  and  extremely  important ;  their  skeleton  is  formed  by  long 
bones,  the  phalanges,  of  which  each  finger  has  three,  except  the  thumb, 
the  central  phalanx  of  which  is  deficient.  These  bones  are  termed 
the  phalanges,  phalangini,  and  phalangettii.  The  articulations  which 
unite  these  bones  with  each  other,  or  with  the  metacarpus,  are 
strengthened  by  three  ligaments ;  two  of  these  are  lateral,  and  are 
situated  nearer  the  direction  of  flexion  than  that  of  extension ;  an 
anterior,  which  is  enlarged  and  semi-cartilaginons,  and  in  which 
one  or  two  sesamoid  bones  are  frequently  developed,  forming  pulleys 
for  the  flexor  tendons  of  the  fingers,  and  the  uses  of  which  may  be 


DIGITAL  REGION.  299 

compared  to  the  patella.  Each  finger  is  covered,  posteriorly,  by  a 
fibrous  membrane,  formed  by  the  expansion  of  the  tendons  of  its 
extensor  muscles,  to  which,  in  the  last  four  fingers,  the  lumbricales 
muscles  are  added.  Some  ringers,  as  the  thumb,  the  index,  and  the 
little  fing-er,  have  two  extensor  muscles.  Two  lateral  muscles,  an 

o        '  ' 

abductor  and  an  adductor,  also  terminate  on  each  finger.  The  two 
deep  flexor  muscles  send  to  them  some  tendons,  which  in  the  last  four 
fingers  are  interlaced  in  such  a  manner,  that  one  of  them,  that  of  the 
superficial,  divides,  to  allow  that  of  the  deep  to  pass :  these  tendons 
terminate  on  the  last  two  phalanges,  and  are  attached  to  the  first  only 
by  some  vascular  and  synovial  filaments,  and  not  by  a  fibrous  expan- 
sion, as  has  been  asserted  ;  they  are  enclosed  in  an  osseo-fibrous  canal, 
which  proceeds  from  the  metacarpo-phalangean  articulation  to  that 
of  the  phalangini  and  phalangettii ;  this  canal  is  formed,  posteriorly, 
by  a  groove  in  the  phalanges,  and  at  the  articulations  by  their  anterior 
ligament ;  it  is  composed,  on  the  contrary,  in  its  anterior  three  fourths, 
by  a  fibrous  membrane,  continuous  above  with  the  transverse  and  in- 
ferior metacarpal  ligament ;  it  is  very  strong  at  the  central  part  of  the 
first  and  second  phalanx,  and  it  is  interrupted  in  some  other  parts : 
this  membrane  is  formed  of  transverse  fibres  in  those  parts  where  its 
resistance  is  slight,  but  at  the  first  and  second  phalangeal  articulations 
it  is  reduced  to  two  oblique  fasciculi,  which  are  crossed  crucially. 
This  arrangement,  which  is  generally  but  little  known,  causes  four 
large  openings  ;  two  anterior,  through  which  the  synovial  membrane 
is  seen,  and  two  others  which  are  lateral,  through  which  the  vessels 
penetrate.  Two  narrow  and  very  rounded  foramina  are  constantly 
situated  on  the  sides  of  the  metacarpo-phalangean  articulation,  at  the 
origin  of  the  fibrous  sheath  :  they  contain  two  arterial  filaments : 
finally,  a  very  moist  synovial  membrane  is  doubled  on  its  parietes,  and 
on  the  tendons  which  it  protects.  Two  arteries  pass  laterally,  and  a 
little  anteriorly,  through  each  finger ;  they  are  the  collateral  arteries, 
which  are  often  enlarged  by  some  dorsal  twigs  from  the  metacarpus. 
These  arteries  come  from  the  palmar  arches,  and  particularly  from  a 
trunk  situated  in  the  space  between  two  contiguous  fingers,  which 
trunk  bifurcates  at  the  metacarpo-phalangean  articulation.  At  the 
end  of  the  finger,  these  vessels  become  entirely  anterior ;  they  anasto- 
mose in  the  pulp  by  arches,  from  the  convexity  of  which  proceed  some 
anastomosing  branches,  which  are  also  in  arches,  and  which  then 
terminate.  Some  filaments  leave  these  collateral  arteries  at  the  arti- 
culations ;  they  go  backward,  and  terminate  in  the  posterior  soft  parts ; 
of  these  twigs,  the  latter  is  larger  than  the  others,  and  forms  with  that 
of  the  opposite  side  an  arch,  which  surrounds  the  attached  extremity 
of  the  nail.  The  arrangement  of  the  digital  veins  differs  entirely  from 


300  TOPOGRAPHICAL   ANATOMY. 

that  of  the  arteries  :  no  one,  hitherto,  has  described  or  figured  them 
satisfactorily ;  it  is  difficult  to  inject  them,  on  account  of  thei.r  number- 
less anastomoses,  into  which  the  injection  flows,  when  it  is  arrested 
by  the  valves  :  we  have,  however,  a  fine  preparation,  which  is  figured 
in  Plate  YIII.,  Figures  1  and  2  ;  the  principal  twigs  of  these  veins 
are  situated  ori  the  back  of  the  finger,  where  they  form  a  slightly 
complex  plexus.  They  arise,  on  the  contrary,  on  its  anterior  face,  by 
numerous  roots,  which  form  a  fine  plexus,  the  meshes "pf  which  repre- 
sent quadrangular  figures:  this  anterior  plexus  communicates  with 
the  posterior,  by  three  principal  branches,  situated  on  the  inside  and 
outside  of  the  digital  articulations :  we  sometimes  find,  in  the  course 
of  the  collateral  arteries,  a  very  small  vein,  which,  never  exists  the 
whole  length  of  the  finger,  but  only  at  the  metacarpo-phalangean  arti- 
culation. Most  of  the  lymphatic  vessels,,  like  the  veins,  are  dorsal. 
There  are  four  nerves  for  each  finger ;  two  palmar,  and  two,  dorsal. 
They  are  termed  collateral,  on  account  of  their  position  ;.  they  have 
been  wrongly  described  as  anastomosing  in  arches  at  the  extremity  of 
the  fingers.  The  median  and  ulnar  nerves  give  off  the  palmar ;  the 
median  to  the  thumb,  the  index  finger,  the  middle  finger,  and  the  outer 
part  of  the  ring  finger;  the  ulnar,  to  the  inner. side  of  the  ring  finger, 
and  to  the  little  finger.  The  end  of  the  radial  nerve  and  a  branch  of  the 
ulnar  nerve  give  off  the  dorsal,  which  are  also  distributed  to  the  fingers, 
so  that  the  median  nerve  on  the  outside  receives  a  filament  of  the 
radial  nerve,  and  another  from  the  ulnar  nerve  on  the  inside.  The 
skin  of  the  fingers  is  fine  and  very  papillary,  especially  in  the  direction 
of  flexion ;  it  is  extremely  tense  in  every  part,  and  it  is  united  anteri  - 
orly  to  the  fibrous  sheath  by  some  dense  cellular  filaments,  in  the 
spaces  between  which,  many  very  minute  adipose  vesicles  are  situated  : 
the  dorsal  cellular  tissue  is  looser  and  less 'adipose  than  in  the  other 
points. 

2.  Relations.  The  relations  of  the  elements  of  the  fingers  are  ex- 
tremely simple,  and  must  be  considered  successively,  anteriorly,  pos- 
teriorly, arid  laterally.  In  the  first  direction  we  find,  in  successive 
layers  ;  the  skin,  an  abundant  cellular  and  adipose  tissue, 'attaching 
the  skin,  intimately  to  the  deeper  parts  and  containing  in  its  areolse  some 
very  minute  arteries,  the  anterior  venous  plexus,  the  branches  of  which 
£,re  almost  sub-cutaneous ;  more  deeply  and  at  the  pulp  only,  we  find 
the  arterial  arch  and  the  anterior  collateral  arteries  :  then  below,  the 
phalangettean.  flexor  tendon,  and  the  phalangette,  the  extremity  of 
which  is  rough,  and  on  which  are  attached  some  cellular  filaments 
which  adhere  on  the  other  hand  to  the  skin.  (See  PI.  VII.  fig.  3.) 
At  the  first  two  phalanges,  the  skin  and  sub-cutaneous  .tissue  being 
removed,  we  find  the  sheath  of  the  flexor  tendons,  presenting  the 


DIGITAL  REGION.  301 

% 

openings  we  have  mentioned,  and  contiguous  on  the  outside  to  the 
collateral  vessels  and  nerves,  the-  nerve  being  situated  on  the  outside, 
and  the  artery  on  the  inside  ;  we  perceive .  some  arterial  filaments, 
which  penetrate  into  -the  openings  of  the  sheath,  surrounded  with 
adipose  bodies,  which  establish  a  communication  between  the  external 
cellular  tissue  and  that  concealed  by  the  sheath.  If  we  open  this 
sheath,  we  seo-the.  tendon  of  the  superficial  flexor,  and  then  that  of  the 
deep  flexor  ;  but  they  soon  cross,  this  relation  changes,  and  the  latter 
becoming  superficial  covers  in  its  turn  the  former.  If  we  raise  these 
tendons,  we  see  that  they  adhere'  to  the  sheath  in  some  parts  by  bands, 
which  are  shown  by  injections  to  be  formed  of  vessels  covered  by  the 
synovia!  membrane.  Beyond,  .we  see  the  anterior  face  of  the  pha- 
langes and  of  their  articulations.  On  the  dorsal  face,  the  elements  of 
the  fingers  are  arranged  much  more  simply  and  appear  in  the  following 
order:  the  skin,  its  sub-cutaneous  cellular  tissue,  which  is  looser  and 
less  adipose  than  anteriorly,  and  in  which  we  find  the  dorsal  venous 
plexus,  the  small  dorsal  arteries,  'and  the  •  dorsal  collateral  nerves : 
more  deeply  comes  the  aponeurosis  of  the  extensor  and  lumbricales 
muscles ;  finally,  the  phalanges  arid  their  articulations,  which  are  open 
in  this  direction.  At  the  phalangette,  under  the  skin,  we  find  the  arte- 
rial arch,  which  sends  numerous  branches  into  the  matrix  of  the  nail 
and  into  the  skin  reflected  under  it.  The.  parts  which  cover  the  ske- 
leton of  the  fingers  on  the  .sides  are,  the  skin;  a  sub-cutaneous  cellular 
tissue,  similar  to  that  which  exists  posteriorly,  and  containing  the  dorsal 
arteries,  the  oblique  veins  which  unite  the  anterior  venous  plexus  with 
the  posterior ;  above,  the  tendons  of  the  inter-ossei  and  lumbricales 
muscles. 

Development.  The  period  when  the  inter-digital  membrane,  men- 
tioned above,  begins  to  disappear,  has  not  been  accurately  determined  ; 
Meckel  states  that  it  is  at  the  third. month  of  fetal  existence.  In  the 
child,  the  canal  of  the  flexor  tendons  is  formed  only  by  the  phalanges, 
the  anterior  groove  of  which  is  deficient ;  as  age  advances,  the 
osseous  part  of  this  passage  increases  progressively,  at  the  expense  of 
the  fibrous  membrane. 

Varieties.  The  vessels  and  nerves  of  the  fingers  are  sometimes 
given  off  by  trunks,  arranged  abnormally  in  the  palm  of  the  hand :  but 
if  the  fingers  receive  the  nerves  and  vessels  necessary  for  the  support 
of  their  vitality  and  their  sensibility,  it  is  of  little  importance  whence 
they  come,  provided  these  elements  always  have  the  same  .relations. 

Uses.  The  functions  of  the  fingers  are  to  execute  extensive  motions 
of  flexion  and  extension 'in  all  their  articulations.  Motions  of  adduc- 
tion and  abduction  belong  only  to  the  metacarpo-phalangean  articu- 
lation. The  pulp  of  the  finger  is  admirably  adapted  to  be  a  most  perfect 


302  TOPOGRAPHICAL    ANATOMY. 

organ  of  touch ;  it  is  supplied  with  numerous  nerves,  the  skin  is 
attached  there  very  firmly  to  the  bones,  and  supported  by  a  very  elastic 
fatty  cushion,  to  which  the  phalangette  and  the  nail  serve  as  a  point 
of  support. 

Pathological  and  operative  deductions.  All  or  some  of  the  fingers 
are  sometimes  united  in  the  adult  in  the  same  manner  as  in  the  fetus, 
by  a  prolongation  of  the  skin.  Whether  this  defect  be  congenital,  or 
produced  by  treating  a  burn  improperly,  it  is  always  remedied  by  a 
simple  incision.  Supernumerary  ringers  have  sometimes  the  normal 
structure ;  but  most  generally  they  are  normal  only  in  their  external 
form :  they  are  simple  fleshy  excrescences.  The  fingers  are  dislocated 
only  anteriorly  and  posteriorly ;  they  are,  in  general,  easily  reduced ;  we, 
however,  have  seen  Dupuytren  find  it  very  difficult  to  reduce  a  meta- 
carpo-phalangean  dislocation  of  the  thumb,  which  was  not  reduced 
till  the  cause  of  the  difficulty  had  been  discovered  by  an  incision  to  be 
the  gliding  and  interposition  of  a  portion  of  its  small  flexor  tendon 
between  the  articular  surfaces.*  Wounds  of  the  fingers,  particularly 
of  the  anterior  part,  are  always  very  painful ;  if  made  with  a  pricking 
instrument  they  may  be  followed  with  violent  inflammation,  resulting 
from  the  imperfect  injury  of  some  nervous  filament.  Inflammation  of 
the  finger  is  termed  panaris :  it  may  be  situated  exclusively  in  the 
skin,  in  the  sub-cutaneous  tissue,  in  the  tendinous  sheath,  in  the  peri- 
osteum of  the  phalanges,  or  it  may  affect  all  these  organs  at  the  same 
time.  Deep  inflammation  is  very  serious  ;  the  least  symptoms  which 
it  can  cause  are,  the  loss  of  the  flexor  tendons,  and  even  of  the  pha- 
langes, which  may  die.  A  very  remarkable  circumstance  is,  that  after 
necrosis,  the'  bone  is  never  reproduced.  Superficial  inflammations, 
if  not  attended  to  very  soon,  may  become  deep,  from  the  vascular  and 
cellular  continuity  of  the  parts.  The  abundance  of  the  nerves,  the 
compact  nature  of  the  skin  of  the  finger,  particularly  its  intimate  adhe- 
sion to  the  bones,  and  its  tension,  which  prevents  it  from  yielding,  ex- 
plain the  extreme  pain,  the  fever,  and  the  severe  symptoms  often  seen 
in  these  diseases.  To  remove  these  pains  and  the  compression,  Boyer 
recommends  that  the  part  be  laid  open  before  pus  forms,  but  other 
surgeons  advise  us  to  wait.  When  the  suppuration  is  superficial,  we 
must  always  be  careful  of  the  sheaths  of  the  tendons  ;  but  they  must 
be  opened  as  soon  as  pus  enters  into  them.  We  cannot  tell,  a  priori, 
whether  pus  be  or  be.  not  contained  in  the  sheath ;  hence,  in  the  first 
incision,  this  must  be  avoided  ;  we  afterwards  examine  with  a  director, 

*  Pailloux  has  made  some  researches,  from  whence  it  would  seem  that  the  interposition  of 
the  anterior  ligament  of  the  articulation,  between  the  articular  surfaces,  is  one  of  the  principal 
obstacles  to  the  reduction  of  dislocations  of  the  fingers:  this  seems  to  us  more  probable,  as 
this  ligament  is  the  place  where  the  scsamoid  bones  are  formed.  PI.  VII. 


DIGITAL  REGION.  303 

to  ascertain  whether  this  presents  any  fistulous  openings,  and  if  this 
be  the  case,  we  must  open  it,  in  order  to  prevent  the  pus  from  burrow- 
ing in  its  canal  towards  the  hand,  which  is  a  serious  accident.  These 
attempts,  however,  must  always  be  made  gently,  and  we  must  not 
forget  that  natural  openings  may  be,  and  have  been,  mistaken  for 
fistulous  passages ;  this  error  is  very  serious,  as  having  opened  the 
sheaths  the  tendons  exposed  to  the  air  constantly  exfoliate :  this  is  fol- 
lowed with  the  loss  of  the  motion  of  flexion  and  with  a  permanent 
state  of  extension.  This  latter  inconvenience  always  attends  a  panaris 
if  situated  in  the  tendon.  We  have  often  observed,  that  after  the  first 
extension  of  a  finger,  which  has  lost  its  flexor  tendons,  a  forced  flexion 
supervenes.  Dissection  has  shown  us  that  this  secondary  phenomena 
results  from  the  coarctation  and  collapse  of  the  useless  sheath.  Super- 
ficial panaris  is  sometimes  situated  only  in  the  matrix  of  the  nail, 
which  then  is  often  separated,  although  it  re-appears,  if  the  skin  be  not 
deeply  affected.  The  wasting  of  the  end  of  the  finger,  in  persons 
affected  with  phthisis,  removing  from  the  loose  extremity  of  the  nail 
its  point  of  support,  this  nail  curves  slightly  in  the  form  of  a  hook. 
Dropsy  of  the  tendinous  sheaths  of  the  fingers  is  not  unfrequent ;  it  is 
marked  externally  by  two  tumors,  which  correspond  to  the  weak  parts 
of  the  fibrous  membrane.  We  have  dissected  a  cadaver  where  the 
fingers  presented  anteriorly  numerous  small  lipomata.  The  fingers 
may  be  amputated  or  extirpated  :  amputations  are  generally  performed 
in  the  phalangean  articulations  ;  two  flaps  may  be  made,  an  anterior 
and  a  posterior,  or  only  an  anterior.  The  position  of  the  vessels  and 
nerves  is  not  a  sufficient  reason  for  making,  as  has  been  proposed,  two 
lateral  flaps,  which  would  be  opposite  according  to  the  great  diameter 
of  the  osseous  surface.  Whether  we  divide  the  dorsal  or  the  posterior 
face,  we  can  judge  of  the  importance  of  our  remarks  on  the  relations 
of  the  cutaneous  grooves  with  the  articulations  :  if  no  posterior  flap  be 
made,  and  if  we  commence  the  incision  posteriorly,  we  must  cut  one 
line  below  the  articular  angle :  if,  on  the  contrary,  we  commence  ante- 
riorly, the  incision  must  vary.  After  amputation  in  the  phalangeal 
articulation,  the  stump  may  be  flexed  by  the  phalangean  tendon  of  the 
superficial  flexor.  This  tendon,  on  the  contrary,  is  divided  in  ampu- 
tation at  the  first  joint,  and  the  motions  of  flexion  of  the  small  stump 
are  lost,  until  adhesions  of  the  tendons  with  the  cicatrix  restores  the 
action  of  their  flexor  muscles :  we  have  seen  this  several  times  :  the 
synovial  adhesion  of  the  superficial  tendon  with  the  first  phalanx 
would  not  be  sufficient  to  produce  the  flexion  of  the  stump.  We  have 
a  ringer  amputated  at  the  first  phalangeal  articulation,  on  the  summit 
of  which  a  small  unciform  nail  had  formed.  The  fingers  are  easily  ex- 
tirpated, if  we  remember  the  depth  of  the  articulation  :  we  make  two 


304  TOPOGRAPHICAL    ANATOMY. 

small  lateral  flaps,  in  which  the  nerves  and  the  veins  are  situated  ;  we 
must  be  careful  to  cut  very  near  the  finger  which  is  to  be  amputated, 
in  order  to  avoid  the  common  trunk  of  the  collateral  arteries,  situated 
at  the  height  of  the  metacarpal  articulation. 


SECTION     II. 

OF     THE    ABDOMINAL     LIMBS. 

The  abdominal  or  pelvic  limbs  are  articular  prolongations  of  the' 
abdominal  or  pelvic  portion  of  the  trunk. 

In  the  animal  series,  these  limbs  are  less  constant  than  the  thoracic  ; 
they  are  deficient  only  in  the  large- mammalia,  the  cetaceous  animals, 
and  particularly  the  whale,  &c.  They  form  the  posterior  limbs  of 
quadrupeds,  the  claws  of  birds,  and  the  ventral  fins  of  fishes.- 

In  man,  the  length  of  the  inferior  limbs  measures  nearly  half  the 
whole  length  of  the  body  ;  in  this  respect  they  are  a  little  less  than  the 
thoracic  limbs,  which  depends  upon  the  fact  that  one  of  the  faces  of 
their  last  sectionj  the  foot,  rests  on  the  ground,  and  consequently  ex- 
tends the  length  of  the  limb  only  by  its  height ;  they  are  separated  by 
the  breadth  of  the  pelvis,  and  are  placed  upon  an  anterior  plane. 

The  mass  of  the  pelvic  limbs-  is  considerable.  Their  form  is  nearly 
conical;  arid  in  order  to  study  them,  they -must  be  considered  as 
standing  parallel  to  each  other  ;  in  this  position  they  present  an  ante- 
rior face,  which  is  generally  convex,  and  a  little  depressed  at  the  first 
joint;  a  posterior  face,  which  is  also  convex,  particularly  in  the 
centre,  and  in  certain  positions  ;  their  outer  part  forms  in  the  centre  a 
re-entering  angle ;  the  internal  forms,  on  the  contrary,  an  angle 
more  or  less  prominent  in  the  corresponding  point.  Each  of  these 
.lateral  faces  is  marked  by  three  eminences,  on  the  outside  the  great  tro- 
chanter,  the  external  condyl.e  of  the  heel,  and  the  external  malleolus ; 
on  the  inside,  the  sciatic  tuberosityj  the  inner  condyle  of  the  knee  and 
the  internal  malteolus ;  the  first  are  situated  on  the  same  line,  but  this 
is  not  true  of  the  second.  The  base  of  the  pelvic  limb  rests  on  the 
pelvic  trunk  and  blends  with  it,  so  as  to  contribute  on  the  inside  to  cir- 
cumscribe one  of  its  splanchnic  cavities,  the  abdomen ;  its  summit 
rests  on  the  foot,  which  serves  as  its  base  of  support. 

Structure.     The  structure  of  the  abdominal  limb  is  characterized 
by  the  strength  and  length  of  the  bones,  the  solidity  of  the  articulations. 


ABDOMINAL  LIMBS.  305 

the  resistance  of  the  aponeuroses,  the  number  and  size  of  the  muscles, 
the  development  of  the  different  kinds  of  vessels,  while  the  nerves, 
compared  with  the  size  of  the  limb,  are  not  large,  and  the  skin  is  thick. 

Development.  The  development  of  the  abdominal  limbs  is  con- 
nected with  that  of  the  abdominal  part  of  the  trunk,  and  as  this  part 
is  the  most  constant,  these  limbs  are  seldom  deficient  in  monsters  ;  their 
formation,  however,  is  irregular ;  although  the  abdomen  is  the  first 
part  seen  in  the  fetus,  the  limbs  which  proceed  from  it  are  slow  in 
their  development,  particularly  if  compared  with  the  thoracic  limbs. 

Varieties.  In  the  female,  the  pelvic  limbs  are  proportionally  larger 
and  longer  than  in  the  male  ;  in  her,  also,  their  size  depends  on  the 
abundance  of  the  sub-cutaneous  fat,  which  renders  them  more  round. 

Uses.  In  the  lower  limb,  every  thing  is  calculated  for  solidity,  but 
at  the  expense  of  mobility :  the  insertion  of  the  muscles  in  the  levers 
which  they  move  is  less  oblique  than  in  every  other  part,  and  the  latter 
are  frequently  of  the  second  kind ;  finally,  the  compact  nature  of  the 
articulations  also  explains  these  two  results,  which  are  necessary  to 
the  functions  of  the  limb,  as  it  must  constantly  support  the  weight  of 
the  whole  body. 

Pathological  and  operative  deductions.  The  whole  of  the  abdomi- 
nal limbs  are  seldom  deficient,  as  has  already  been  explained.  They 
are  sometimes  united,  and  extend  the  trunk  in  the  form  of  a  tail,  in 
the  monsters  termed  sirenes.  The  solidity  of  their  articulations  renders 
their  dislocations  unfrequent,  although  their  functions,  in  fact,  dispose 
to  them  ;  this  circumstance,  on  the  contrary,  is  very  favorable  to  frac- 
tures. The  great  resistance  of  the  aponeuroses  renders  deep  inflam- 
mations more  serious  here  than  in  any  other  point. 

The  four  great  divisions  of  this  limb  are,  the  haunch,  the  thigh,  the 
leg,  and  the  foot,  which  sections  are  united  by  joints,  the  upper  of 
which  blends  with  the  haunch,  while  the  other  three  serve  as  the -base 
of  important  regions. 

39 


306  TOPOGRAPHICAL   ANATOMY. 

. 


CHAPTER      I. 


FIRST      SECTION      OF      THE       ABDOMINAL       LIMB, 

The  first  section  of  the  abdominal  limb,  the  haunch,  is  the  base  by 
which  it  rests  on  the  trunk.  It  is  composed  of  the  organs  which  cover 
the  two  faces  of  the  iliac  bone  ;  the  haunch  is  analogous  to  the  shoulder 
in  the  thoracic  limb,  and  presents  two  faces ;  one  is  internal,  and  cor- 
responds to  the  abdomen,  and  blends  with  its  parietes,  in  which  we 
have  already  examined  it ;  the  other  is  external,  and  is  directly  con- 
nected with  the  pelvic  limb,  and  forms  on  the  outside  the  gluteal 
region,  while  anteriorly  the  region  of  the  thigh  advances  to  it.  From 
this  external  face,  which  is  common  to  two  regions,  proceeds  the 
coxo-femoral  rarticulation,  remarkable  for  its  depth,  .which  is  increased 
by  a  fibre-cartilaginous  bursa,  and  is  strengthened,  first,  by  an  inter- 
articular  ligament,  which  is  attached  to  .the  iliac  bone,  at  the  base  of 
the  cotyloid  cavity ;  second,  by  a  capsule,  very  strong  above,  on  the 
outside,  and  anteriorly, 'and  weak  in  other  directions;  a  considerable 
adipose  body  fills  the  base  of  the  articulation,  and  communicates  with 
the  extra-articular  tissue,  through  a  fibro -osseous  foramen,  situated  on 
the  inside,  and  serving  .also  for  the  introduction  of  an  important  artery, 
which  distributes  some  ramuscules  to  the  round  ligament,  and  to  the 
head  of  the  femur.  Finally,  a  part  of  the  femur  is  modified  for  this 
articulation,  and  presents  for  this  purpose  its  head,  and  pedicle  or  neck, 
which  is  directed  upward  and  inward,  and  forms  with  the  rest  of  the 
bone  an  angle  of  about  one  hundred  and  twenty  degrees,  which  is  open 
downward  and  inward.  '  This  neck  may  be  divided  into  three  portions ; 
an  inter-articular,  an  extra-articular,  which  is  very  much  marked 
posteriorly,  and  a  third,  which  is  represented  by  the  line  of  insertion 
of  the  fibrous  capsule. 

Development.  The  first  section  of  the  abdominal  limb  is  developed 
at  a  late  period,  and  seems  to  be  the  last  which  is  distinct  in  the  fetus ; 
during  the  whole  of  pregnancy,  it  is  in  a  measure  rudimentary ;  after 
birth,  it  increases  slowly  but  constantly,  until  puberty,  at  which  period 
the  sexual  characters  are  seen. 

Varieties.  Iri  the  male,  the  haunch  is  thrown  slightly  outward, 
and  is  considerably  high ;  the  opposite  is  true  of  the  female.  In 
respect  to  their  arrangement,  numerous  individual  varieties  exist;  in 


REGION  OF  THE  HAUNCH.  307 

some  males,  they  are  very  much  separated,  as  in  the  female ;  while  in 
some  females  they  are  remarkably  near :  sometimes  the  round  ligament 
is  completely  absent,  which  may  depend  on  an  old  rupture. 

Pathological  and  operative  deductions.     The  position  of  the  coxo- 
femoral  articulation  on  the  limits  of  the  haunch  and  thigh  explains 
how  its  diseases  may  extend  into  one  or  the  other  of  these  regions,  or 
in  both  of  them,  as  is  seen  in  dislocation  for  instance.     This  dislocation, 
taking  into  view  the  structure  of  the  articulation,  seems  practicable 
only  downward  and  inward ;  and  yet,  observation  demonstrates,  that 
dislocation  upward  and  outward  is  much  more  common.     A  fact  of 
this  nature  can  depend  only  on  an  anatomical  arrangement ;  Gerdy 
seems  to  me  to  have  placed  the  cause  of  it  correctly  in  the  round  liga- 
ment.    In  motions  of  adduction,  this  inter-articular  fibrous  fasciculus 
raises  from  the  base  of  the  cotyloid  cavity,  the  head  of  the  femur, 
around  which  it  tends  to  rotate;  in  this  manner,  the  summit  of  the 
head  of  the  femur  is  soon  placed  on  the  edge  of  the  cotyloid  cavity, 
and  only  a  slight  muscular  effort  is  necessary  to  produce  dislocation. 
The  neck  of  the  femur  may  be  broken  in  the  three  parts  which  have 
been  mentioned  ;  hence,  three  distinct  kinds  of  fractures  of  this  neck  ; 
some  are  external  to  the  articulation,  and  are  easily  consolidated,  the 
two  fragments  receiving  numerous  vessels;  others,  which  correspond 
to  the  insertion  of  the  fibrous  capsule,  unite  equally  well,  for  the  same 
reason,  and  are  particularly  remarkable  for  the  slight  displacement  of 
the  fragments  ;  the  last,  which  are  entirely  intra-articular,  are  never 
cured,  because  the  upper  fragment  being  almost  destitute  of  vessels, 
becomes  a  foreign  body  in  the  articulation,  and  therefore  cannot  con- 
tribute to  the.formation  of  callus';  this  condition  of  the  upper  fragment 
explains  why  it  is  frequently  destroyed  by  the  friction  of  the  lower 
fragment.     A  want  of  union  in  this  latter  case  has  been  observed  by 
every  person,  and  the  facts  have  led  several  distinguished  surgeons, 
particularly  Sir  Astley  Cooper,  to  state,  that  this  fracture  never  unites. 
Although  this  opinion  is  founded  on  an  immense  mass  of  facts,  several 
cases  have  been  mentioned  which  at  first  view  would  seem  to  contra- 
dict it ;  but  we  are  strongly  led  to  believe,  from  what  we  have  gained 
by  dissecting  ten  cases  of  the  fracture  of  the  neck  of  the  femur,  that 
this  difference  of  opinion  arises  from  not  distinguishing  the  three  kinds 
of  fractures  we  have  mentioned.     We  have  now  before  us  four  femurs, 
where  the  neck  has  been  broken  above  the  insertion  of  the^  capsule, 
and  not  the  least  consolidation  exists  in  any  one  of  them.     It  cannot  be 
objected  that  this  fact  depends  on  the  advanced  age  of  the  subjects  whom 
we  have  examined  ;  in  fact,  one  of  them  was  only  thirty-three  years 
old  :  farther,  we  know  very  well  that  some  fractures  of  the  neck  of  the 
femur  are  perfectly  consolidated  in  old  men.     The  objection  which 


308  TOPOGRAPHICAL  ANATOMY. 

some  make  who  speak  of  the  vessels  received  by  the  superior  fragment 
through  the  round  ligament,  is  not  well  founded ;  to  judge  of  it,  we 
must  consider  the  fineness  and  thinness  of  these  vessels,  which  many 
seem  to  admit  theoretically  rather  than  by  direct  examination.  The 
spontaneous  luxation  of  the  coxo-femoral  articulation  is  often  produced 
in  children  by  a  tuberculous  swelling  of  the  cotyloid  cellulo-fatty  body. 
In  one  case  dissected  by  us  at  the  Hospital  des  Enfans,  we  found  on  the 
inside  of  the  cotyloid  cavity  a  tuberculous  mass,  which  communicated 
with  a  similar  production,  situated  on  the  outside,  on  a  level  with  the 
internal  foramen  of  the  articulation  ;  this  external  tumor  seemed  to 
have  extended  from  the  inside  to  the  outside,  by  the  continuity  of  the 
cellular  tissue.  After  these  different  luxations  of  the  femur,  the  head 
of  this  bone  may  go  to  different  parts  ;  we  shall  mention  this  hereafter, 
and  also  the  supplementary  joints  which  take  place  in  this  case. 
We  have  now  to  examine  the  cotyloid  cavity ;  when  freed  from  the 
head  of  the  femur,  it  at  first  contracts,  becomes  triangular,  the  cotyloid 
bursa  tumefies  for  want  of  pressure,  fills  the  whole  cavity,  which  is 
soon  obliterated  by  the  approximation  of  its  parietes,  like  an  alveolus, 
after  the  tooth  is  extracted. 

The  first  part  of  the  abdominal  limb  presents  on  the  inside,  the  iliac 
and  intra-pelvic  regions,  which  we  have  already  mentioned ;  on  the 
outside,  it  is  formed  by  the  gluteal  region,  and  unites  to  the  second 
section  of  the  corresponding  limb, 


GLUTEAL       REGION. 


The  buttock  is  the  upper  and  outer  part  of  the  haunch.  It  is 
bounded  above  by  the  iliac  crest ;  below,  by  a  depression,  termed  the 
groove  of  the  buttock  ;  anteriorly,  by  the  great  trochanter  and  the  supe- 
rior and  anterior  iliac  spine  ;  posteriorly,  by  the  sacrum,  by  the  coccyx, 
and  at  their  level,  by  a  depression,  which  is  continuous  with  that  of 
the  spinal  region  of  the  trunk. 

The  thigh  rests  by  one  side  on  the  pelvis,  on  the  other  it  is  cutane- 
ous, and  is  more  or  less  uniformly  convex ;  we  can  often  see  there, 
and  can  feel  there  below,  a  depression,  bounded  by  two  large  tubero- 
sities  of  bone,  those  of  the  ischium,  and  of  the  great  trochanter. 

Structure.  —  1.  Elements.  The  skeleton  of  the  buttock,  is  particu- 
larly, the  internal  iliac  fossa,  and  the  upper  external  part  of  the  coxo- 
femoral  articulation,  which  has  been  examined  in  describing  the 
haunch  generally,  because  it  belongs  equally  to  the  two  regions  which 
proceed  from  it,  the  gluteal  and  the  femoral.  Below  this  articulation, 
a  large  tuberosity  of  the  femur,  the  great  trochanter,  belongs  to  this 


GLUTEAL  REGION.  309 

region,  in  which  the  skeleton  presents  also  two  osseo-fibrous  foramina, 
termed  the  sciatic,  one  of  which,  the  larger,  is  upper  and  posterior ; 
another,  which  is  smaller,  inferior  and  anterior ;  both  establish  a  com- 
munication with  the  buttock  and  the  interior  of  the  pelvis.  Three  great 
muscles  belong  to  this  region,  and  are  termed  the  glutei  muscles ; 
they  are  distinguished  according  to  their  size.  In  regard  to  the  tex- 
ture of  these  muscles,  we  would  remark,  that  the  terminating  tendon 
of  the  glutens  maximus  is  flattened,  and  expanded  in  thin  layers  on 
each  of  its  faces  ;  that  of  the  gluteus  medius  is  central,  while  that  of 
the  gluteus  minimus  is  expanded  on  its  external  face  only.  The  small 
rotator  muscles  of  the  thigh  are  all  situated  deeply  in  the  buttock ; 
the  pyramidalis,  the  two  gemelli,  the  extremities  of  the  obturators,  and 
the  quadratus  femoris  ;  finally,  a  very  small  portion  of  the  biceps, 
semi-tendinosus,  semi-membranosus,  triceps,  and  adductor  longus 
muscles,  advance  into  this  region,  to  which  they  are  entirely  accessory. 
The  fascia  lata  aponeurosis  arises  in  the  buttock,  and  presents  there 
some  special  characters  ;  it  is  very  thin  posteriorly ;  anteriorly,  on  the 
contrary,  it  is  very  strong,  and  gives  origin  to  the  gluteus  medius 
muscle ;  it  is  attached  to  all  the  periphery  of  the  buttock,  and,  in  fact, 
forms  for  it  an  imperfect  sheath,  open  downward  toward  the  thigh, 
and  upward  on  the  side  of  the  pelvis,  at  the  sciatic  foramina.  The 
fascia  superficialis  also  extends  into  this  point,  and  soon  disappears  in 
the  cellular  tissue.  The  arteries  of  the  buttock  come  almost  exclu- 
sively from  the  hypogastric  artery,  the  gluteal  branch  of  which  belongs 
to  it ;  the  internal  pudic  and  sciatic  arteries  pass  through  this  region, 
and  send  to  it  some  branches,  particularly  the  latter.  All  these  vessels 
come  from  the  pelvis,  through  the  great  sciatic  foramen ;  the  pudic 
artery  alone  passes  through  the  small  sciatic  foramen.  Finally,  the 
two  circumflex  arteries  retrograde,  and  terminate  there  by  anastomosing 
with  the  proper  gluteal  arteries ;  this  circumstance  is  extremely  im- 
portant in  re-establishing  the  circulation,  when  the  upper  part  of  the 
femoral  artery  or  the  external  iliac  artery  has  been  tied.  The  veins 
generally  follow  the  course  of  the  arteries  ;  we,  however,  remark,  that 
we  find  a  superficial  plexus  of  them,  which  is  sometimes  large,  and 
goes  to  the  sub-cutaneous  abdominal  vein.  The  superficial  lymphatic 
vessels  go  to  the  ganglion  and  groin  :  the  deep  follow  the  course  of  the 
gluteal  and  sciatic  arteries,  enter  into  the  pelvis,  and  go  to  the  pelvic 
ganglions.  The  gluteal  nerves  are  distinguished  into  the  superior 
gluteal,  which  are  given  off  by  the  lumbo-sacral  cord,  and  the  inferior, 
which  come  from  the  sacral  plexus ;  the  great  sciatic  nerve,  the  in- 
ternal pudic  nerve,  and  the  small  sciatic  or  posterior  cutaneous  nerve 
of  the  thigh,  pass  through  this  region,  giving  to  it  some  twigs  ;  like 
the  arteries,  they  all  come  through  the  great  sciatic  foramen,  some 


310  TOPOGRAPHICAL  ANATOMY. 

passing  above  the  pyramidalis  muscle,  and  others  below  it.  The  deep 
cellular  tissue  of  the  thigh  is  fatty  ;  it  is  very  loose,  and  is  continuous 
above,  through  the  sciatic  foramina,  with  the  intra-pelvic  tissue,  and 
below,  with  that  of  the  posterior  part  of  the  thigh.  The  superficial 
cellular  tissue  is  entirely  different  and  distinct. from  the  former  ;  it  is 
remarkable  for  its  density,  and  for  the  fat  which  it  contains,  which 
varies  in  quantity ;  some  fibrous  filaments  pass  through  it,  and  increase 
its  resistance.  The  glutens  maximus  muscle  is  separated  from  the 
great  trochanter  by  a  mucous  bursa,  which  is  remarkable  for  its  laxity, 
and  the  septa  which  separate  it.  The  skin  of  the  buttock  is  fine,  and 
slightly  downy,  except  on  the  posterior  limits  of  the  region. 

2.  Relations.     In  regard  to  the  arrangements  of  its  elements,  the 
buttock  is  extremely  simple  ;  they  appear  in  the  following  order  :  the 
skin,  the  sub-cutaneous  cellulo-fatty  layer,  which  is  more  abundant  at 
the  sciatic  tuberosity,  then  the  very  strong  aponeurosis,  anteriorly ; 
more  deeply,  on  the  same  plane,  the  gluteus  maximus,  and  most  of  the 
glutens  medius,  the  whole  of  which,  however,  is  not  seen  until  the 
former  is  divided  ;  under  this  latter,  we  find,  also,  beside  the  vessels 
and  nerves  which  belong  to  it,  the  deep  portion  of  the  gluteus  medius 
muscle^  and  the  sacro-sciatic  ligaments,  the  pyramidalis  muscle,  the 
sciatic  vessels  and   nerves,  resting  from  above  downward,  on   the 
gemellus  superior,  obturator  internus,   gemellus  inferior,  quadratus 
femoris,  and  the  adductor  longus,  and  situated  in  a  depression,  formed 
on  the  inside  by  the  sciatic  tuberosity,  which  is  exposed  with  the 
muscles .  which  are  inserted  in  it,  and  on  the  outside,  by  the  great 
trochanter,  on  i  which  we  perceive  the  mucous  bursa  of  the  gluteus 
maximus,  and  the  upper  extremity  of  the  vastus  externus  muscle. 
With  the  sciatic  vessels  and  nerves,  which  come  from  the.  pelvis, 
through  the  great  sciatic  notch,  below  the  pyramidalis  muscle,  we 
find  the  internal  piidic  vessels  and  nerves,  which  soon  leave  the 
former,  and  re-enter  into  the  pelvis  through  the  small  sciatic  foramen, 
embracing  in  an  angle  the  sciatic  spine.     Under  the  gluteus  medius 
muscle  we  find,  above,  the  iliac  fossa ;  below,  the  gluteus  minimus 
muscle,  separated  from  the  gluteus  medius  by  the  principal  branches 
of  the  superior  gluteal  vessels  and  nerves,  particularly  by  an  anasto- 
motic  arch,  formed  between  the  gluteal  artery  and  the  external  circum- 
flex artery.     Finally,  if  we  remove  the  gluteus  minimus,  .with  the 
muscles  attached  to  the  trochanter,  we  discover  the  upper  and  posterior 
parts  of  the  coxo-femoral  articulation.     The  quadratus  muscle,  parti- 
cularly, covers  the  tendon  of  the  obturator  externus,  and  the  ascending 
and  anastomotic  branch  of  the  internal  circumflex  artery. 

Development.    In  very  young  children,  the  buttock  projects. but 


GLUTEAL  REGION.  311 

slightly  ;.and  yet,  the  quantity  of  fat,  in  proportion  to  the  development 
of  the  muscles,  is  very  great. 

Varieties.  In  the  female,  the  buttock  is  much  more  rounded  than 
in  the  male ;  in  the  latter,  the  sciatic  tuberosity  and  the  trochanter, 
and  the  groove  between  them,  are  developed  in  the  highest  degree. 
The  prominence  of  the  buttock  varies  in  different  individuals ;  the 
most  curious  of  these  varieties  is  undoubtedly  that  presented  by  the 
female  Housoanas,  a  tribe  of  Hottentots  ;  it  consists  in  a  local  obesity 
of  the  buttock,  which  has  been  confounded,  but  improperly,  with  the 
apron. 

Uses,  The  buttock  is  formed  principally  by  a  group  of  muscles, 
which  act  very  powerfully  in  standing  erect ;  hence  the  general  uses 
of  this  region,  which  are  much  less  developed  in  animals  who  have  a 
horizontal  posture  than  in  man,  in  whom  it  forms  one  of  his  specific 
characters. 

Pathological  and  operative  deductions.  Whatever  may  be  the 
cause  which  produces  dislocation  of  the  head  of  the  femur  upward 
and  outward,  it  is  drawn  up  by  the  action  of  the  gluteal  muscles,  and 
glides  on  the  external  iliac  fossa,  below  the  gluteus  minimus  muscle, 
the  insertion  of  which,  bounds  its  displacement;  the  thigh  then  be- 
comes more  convex  upward,  and  more  flattened  downward.  If  the 
dislocation  remains  unreduced,  the  head  of  the  femur,  left  to  itself, 
presses  on  the  periosteum  of  the  iliac  bone ;  hence  the  vessels  collapse, 
and  consequently  the  corresponding  parts  of  the  bone  waste  ;  pheno- 
mena which  may  be  considered  as  the  origin  of  the  accidental  cavity, 
which  forms  after  a  certain  time  ;  we  add,  that  the  surrounding  peri- 
osteum tumefies,  and  throws  out  a  coagulable  matter,  which  changes 
successively  into  cartilage,  and  then  into  bone,  and  forms,  by  fusing 
with  the  bone,  of  which  it  is  an  accidental  epiphysis,  the  edge  of  the 
new  cavity.  We  have  found  flat  and  lenticular  bodies,  of  a  semi- 
cartilaginous  consistence,  developed  in  the  mucous  bursa  of  the  gluteus 
maximus  muscle.  The  pus  of  gluteal  abscesses  may  be  produced  by 
a  disease  of  this  region ;  it  may  also  come  there  from  the  thigh,  or 
from  the  pelvis,  passing  through  the  great  sciatic  foramen  ;  they  have 
already  been  mentioned.  Erectile  tumor's  and  aneurisms  are  some- 
times developed  in  the  buttock,  under  its  muscles ;  they  are.  too  deep 
to  admit  of  treatment ;  in  one  case  of  this  kind,  Dr.  Stevens,  of  St. 
Croix,  has  tied  the  internal  iliac  artery  with  success,  a  difficult  and 
hazardous  operation,  which  has  already  been  mentioned  when  speaking 
of  the  iliac  and  costo-iliac  regions.  Some  cases  of  sciatic  hernia  have 
been  described  ;  in  all  cases  mentioned,  the  tumor  was  discerned 
with  difficulty  externally,  and  was  always  covered  by  the  gluteus 
maximus  muscle.  The  position  of  this  tumor,  in  respect  to  the  sciatic 


31  TOPOGRAPHICAL  ANATOMY. 

vessels  and  nerves,  has  never  been  mentioned ;  from  the  anatomical 
arrangement  of  the  parts,  we  may  suppose  that  it  glided  before  them, 
and  that  it  was  enveloped  with  them  posteriorly ;  on  account  of  this 
arrangement,  Cooper  directs  us,  if  the  case  presents  itself,  to  divide  the 
strangulation  anteriorly.  No  person  has  mentioned  the  direction  in 
which  the  external  incision  should  be  made ;  on  the  cadaver,  it  is  very 
easy  to  come  to  the  sciatic  ring,  by  cutting  in  the  groove  of  the  buttock, 
following  the  oblique  direction  of  the  lower  edge  of  the  gluteus  maxi- 
mus  muscle,  which  is  raised  above ;  after  this  period  of  the  operation, 
we  find  the  sciatic  vessels  and  nerves,  which  must  be  avoided. 


CHAPTER      II 


SECOND       PART       OF      THE       ABDOMINAL       LI  MB. 

The  thigh  is  the  second  section  of  the  abdominal  limb  ;  its  limits 
are  more  exact  superiorly  than  inferiorly ;  by  uniting  upward  and 
forward  with  the  abdominal  wall,  it  contributes  to  form  the  groin, 
which  has  already  been  mentioned.  At  its  lower  part,  on  the  contrary, 
it  forms  one  of  the  elements  of  the  knee  ;  hence  the  two  regions,  the 
crural  region,  and  that  of  the  knee. 


1  .       CRURAL       REGION. 

The  crural  region  is  distinguished  from  the  buttock  upward'  and 
backward  by  the  groove  of  the  buttock,  and  from  the  abdominal  wall 
upward  and  forward,  by  the  groin  ;  while  on  the  inside,  a  groove  filled 
with  follicular  openings,  and  which  corresponds  to  the  ascending  ra- 
mus  of  the  ischium,  separates  it  from  the  external  genital  region ; 
below,  it  is,  in  fact,  blended  with  the  knee,  and  they  can  be  separated 
only  artificially,  by  a  line  drawn  circularly  four  fingers'  breadth  above 
the  patella. 

The  thigh  has  the  form  of  a  truncated  cone,  the  base  of  which  is 
situated  in  the  pelvis,  and  the  summit  in  the  knee  ;  it  is  slightly  flat- 
tened in  an  opposite  direction  superiorly  and  inferiorly  ;  its  direction 
is  oblique  from  above  downward  and  from  without  inward  ;  its  length 
measures  nearly  a  quarter  of  that  of  the  whole  body. 


CRURAL  REGION.  313 

The  thigh,  although  generally  rounded,  presents  some  prominences 
and  depressions,  most  of  which  are  muscular  ;  thus,  in  leaning,  the 
relief  of  the  sartorius  muscle  is  seen  proceeding  from  the  anterior  and 
superior  part  toward  the  internal ;  another  prominence  leaves  the  pubis 
and  descends  backward  and  outward  ;  it  is  formed  by  the  fasciculus  of 
the  adductor  muscles,  and  circumscribes,  with  the  preceding,  a  trian- 
gular depression,  the  inguinal  hollow,  in  which  we  readily  feel  the 
pulsations  of  the  crural  artery.  The  anterior  and  external  faces  of  the 
thigh  are  more  or  less  generally  convex,  on  account  of  the  special 
direction  of  the  femur,  and  also  of  the  size  of  the  fleshy  masses  which 
cover  it.  The  internal  and  posterior  faces  are  less  convex  than  the 
first,  for  an  opposite  reason ;  in  the  centre  of  the  internal  face,  we  can 
feel,  by  pressing  firmly,  the  pulsations  of  the  crural  artery,  which  rests 
almost  directly  on  the  femur.  On  the  posterior  face  appears  the  fasci- 
culus of  the  posterior  muscles,  which  fasciculus  is  at  first  single  and 
directed  obliquely  outward,  and  then  separated  into  two  secondary 
fasciculi,  which  contribute,  as  we  shall  see,  to  form  the  popliteal 
space. 

Structure.  —  }..  Elements.  The  femur  forms  the  skeleton  of  the 
thigh  ;  it  belongs  to  it  almost  solely  by  its  centre,  which  is  arched  ante- 
riorly and  perfectly  compact ;  the  direction  of  this  bone  is  that  of  the 
whole  region  ;  all  its  motions,  in  its  upper  and  lower  articulations,  are 
performed  by  superficial  and  deep  muscles  ;  the  first  extend  the  whole 
length  of  the  thigh,  and  even  beyond  this ;  the  second  are  much 
shorter  ;  among  the  deep  muscles  we  will  mention  particularly,  the 
triceps  which  directly  covers  the  femur,  the  fibres  of  which  are  very 
much  shorter  than  those  of  the  superficial  muscles  ;  most  of  the  other 
muscles  are  situated  inward  and  backward  ;  but  few  exist,  on  the  con- 
trary, outward  and  forward.  In  the  latter  points  we  find  only  the 
tensor  vaginae  femoris,  the  rectus  femoris,  and  the  sartorius,  while  on 
the  inside,  the  mass  is  much  larger,  and  is  formed  by  the  gracilis  and 
the  adductor  muscles,  which  are  four  in  number,  if  we  include  the 
pectineus*  muscle ;  posteriorly,  we  see  the  biceps,  the  semi-membra- 
nosus,  and  the  semi-tendinosus,  which  may  be  considered  as  the  cords  of 
the  arc  represented  by  the  femur.  The  psoas  and  iliacus  muscles  an- 
teriorly, and  the  glutens  maximus  posteriorly,  send  their  lower  extre- 
mities to  this  part. 

A  very  firm  aponeurosis  covers  all  these  muscles,  to  which  it  sends 
remarkable  sheaths,  which  are  formed  by  the  septa  given  off 
from  its  inner  face,  and  which  terminate  in  the  linea  aspera  of  the 

*  The  pectineus  muscle  has  the  position,  form,  direction,  structure,  and  uses  of  the  other 
adductors. 
40 


314  TOPOGRAPHICAL  ANATOMY. 

femur.  The  crural  aponeurosis,  or  the  fascia  lata,  is  continuous  up- 
ward and  backward  with  that  of  the  buttock,  upward  and  forward 
with  the  crural  arch,  and  below  this,  with  the.  fascia  iliaca  on  the  out- 
side, while  on  the  inside,  it  is  attached  to  the  external  lip  of  the  pubic 
arch  ;  finally,  this  aponeurosis  is  continuous  below  on  the  knee.  The 
strongest  sheath  of  the  muscles  of  the  thigh  is  that  common  to  the 
triceps  and.  the  rectus  femoris  muscles.*  The  sartorius,  the  adductors, 
the  gracilis  and  pectineus  muscles,  have  separate  sheaths ;  one  alone  en- 
velopes posteriorly  the  deep  muscles,  vessels,  and  nerves ;  this  posterior 
sheath  continues  .upward  under  the  buttock  to  the  sciatic  notch  ;  below, 
it  communicates  with  the  popliteal  space.  The  femoral  vessels  are 
also  provided  with  a  triangular  sheath,  which  is  very  strong  and  very 
broad  above,  where  it  constitutes  the  crural  canal,  which  will  be  de7 
scribed  minutely  when  speaking  of  the  relations  of  the  crural  region; 
finally,  the  sheath  of  the  psoas  and  iliacus  muscles  continues,  like  these 
muscles,  to  the  thigh,  where  it  ceases  to  be  formed  by  the  iliac  fascia. 
Several  openings  in  the  fascia  lata  give  passage  to  vessels  and  nerves, 
which  sometimes  from  deep  become  superficial,  but  much  more  fre- 
quently have  the  opposite  arrangement.  The  most  remarkable  of  these 
openings  is  that  of  the  internal  saphena  vein  at  the  base  of  the  crural 
canal. 

Most  of  the  crural  arteries  come  from  a  common  trunk,  situated  suc- 
cessively on  the  anterior,  internal,  and  posterior  faces  of  the  region, 
and  which  passes  through  it  in  the  course  of  a  line  drawn  from  the 
centre  of  the  crural' arch  toward  the  posterior  and  internal  part  of  the 
inner  condyle  of  the  femur.  In  the  normal  state>  this  trunk  gives  off 
from  its  upper  part  an  inch  and  a  half  below  the  Fallopian  ligament,  a 
considerable  branch,  which  is  often  as  large  as  itself;  this  is  the  deep 
crural  artery,  which  becomes  deeper  as  it  descends,  and  gives  off  most 
of  the  special  arteries  of  the  thigh;  first,  the  two  circumflex  arteries, 
which  embrace  the  neck  of  the  femur  and  then  go  toward  the  buttock, 
iri  which  they  anastomose  with  the  gluteal.  arteries,  while  the  internal 
alone,at  the  obturator  foramen, unites  broadly  with  the  obturator  artery. 
The  two-  circumflex  arteries  form,  on  the  respective  limits  of  the  thigh 
and  of  the  pelvis,  a  complete  arterial  circle,  which  unites  the  systems 
of  both  regions,  and  which  may  supply  the  principal  trunk  in  this 
part:  second,  the  perforating  arteries,  which  may  also  be  called  the 
posterior  crural  arteries,  and.  which,  in  fact,  from  their  origin,  all  go 
backward  and  form,  by  terminating  in  two  branches,  an  anastomosis, 
between  the  arteries  of  the  buttock  and  those  of  the  knee,  an  arrange- 
ment highly  important  to  the  collateral  circulation.  The  deep  femoral 

*  Sometimes  the  rectus  femoris  is  contained  in  a  special  and  very  thin  sheath. 


CRURAL  REGION.  315 

artery  nourishes  the  inferior  and  posterior  parts  of  the  thigh,  while  the 
external  and  anterior  parts  receive  a  considerable  branch,  given  off  by 
the  femoral  artery  at  its  external  and  upper  side ;  this  branch  is  the 
external  muscular  artery,  the  origin  of  which  varies  very  much.  . 

The  veins  of  the  thigh  follow  the  course  of  the  arteries  in  almost 
every  part ;  nevertheless,  in  this  respect,  they  must  be  divided  into 
sub-aponeurotic  and  sub-cutaneous  ;  the  first  may  exclusively  be  said 
to  attend  the  arteries ;  the  arrangement  of  the  second  is  entirely  differ- 
ent. Among  the  sub-aponeurotic  veins^  the  deep  crural  vein  com- 
mences by  anastomosing  with  the  external  saphena  in  the  popliteal 
space,  as.  is  seen  in  PL  XVI.  ;  the  superficial  veins  also  form  a  fine  sub- 
cutaneous plexus,  all  the  branches  of  which  converge  inward  and  go 
into  the'femoral  portion  of  the  internal  saphena  vein,  which  also  receives 
above,  the  superficial  veins  from  the  costo-iliac  and  testicular  regions, 
while  it  is  generally  united  also  with  the  external  saphena  vein  by  a 
considerable  branch  of  the  latter,  which  g'oes  obliquely  towards  it. 
The  internal  saphena  vein  is  situated  successively  on  the  inside  and 
at  the  anterior  part  of  the  thigh,  in  proportion  as  it  ascends ;  finally, 
above,  it  passes  into  a  special  foramen  of  the  fascia  lata  aponeurosis, 
and  terminates  in  the  crural  vein. 

Numerous  lymphatic  ganglions  occupy  the  inguinal  hollow,  some  of 
which  are  superficial  and  others  deep ;  the  term  sub-aponeurotic  ap- 
plied to  these  latter  is  correct  only  in  part,  because  they  are  situated 
only  in  the  sheath  of  the  femoral  vessels,  (the  crural  canal:)  conse- 
quently they  are  simply  covered  by  a  very  thin  layer,  of  the  fascia  lata, 
and  are  hot  situated  entirely  below  it.  The  superficial  ganglions  of 
the  inguinal  hollow-  receive  all  the  superficial  lymphatic  vessels  of  the 
corresponding  limb,  those  of  the  testicular  region  of  the  perine- 
um, of  the  haunch,  and  of  the  sub-.umbilical  part  of  the  costo-iliac 
region.  The  deep  ganglions  receive  the  deep  crural  lymphatic  vessels. 
The  nerves  of  the  thigh  come  from  the  sacral  or  lumbar  plexuses  ;  'the 
latter  supply 'its  anterior,  internal,  and  external  parts,  the  branches  of 
the  former  go  exclusively  to  the  posterior  face  of  this  region  :  all  are 
superficial  or  deep ;  the  superficial  nerves  'on  the  outside  are  the  in - 
guino-cutaneous  branch  ;  inward  and  forward,  the  genito-crural  and 
some  filaments  of  the  crural  nerve ;  internally  and  anteriorly,  the 
genito-crural,  and  some  filaments  of  the  crural  nerve  ;  posteriorly,  the 
small  sciatic  nerve,  the  posterior  cutaneous  nerve  of  the  thigh.  The 
deep  nerves  are  three ;  the  great  sciatic  nerve,  which  merely  passes 
through  this  region  and  gives  off  no  filaments ;  the  crural  and  the 
sub-pubic,  which  resolve  themselves  into  a  great  many  branches, 
nearly  all  of  Which  go  exclusively  to  the  thigh,  except  the  internal  sa- 
phena branch  of  the  first,  which  goes  to  the  parts  below.  In  respect 


316  TOPOGRAPHICAL  ANATOMY. 

to  position  arid  destination,  the  sciatic  nerve  is  posterior,  the  crural  is 
anterior  and  external,  the  sub-pubic  or  obturator  is  internal. 

The  sub-cutaneous  cellular  tissue  of  the  thigh  is  abundant  anteriorly 
and  internally ;  it  is  moderately  loose ;  the  sub-aponeurotic  tissue  is 
very  abundant  posteriorly,  around  the  sciatic  nerve  ;  the  superficial 
and  deep  fat  presents  the  same  arrangement  as  the  cellular  tissue,  and 
is  more  abundant  under  the  skin  than  in  any  other  part.  Finally,  the 
skin  of  the  thigh  is  generally  thick  and  resisting,  but  it  presents  these 
properties  particularly  anteriorly  and  on  the  outside ;  internally  and 
posteriorly,  it  is  proportionally  remarkable  for  its  fineness  and  smooth 
appearance. 

2.  Relations.  The  skin,  the  sub-cutaneous  cellulo-fatty  tissue,  and 
the  superficial  fold  of  the  fascia  lata,  form  three  layers,  which  are  com- 
mon to  the  whole  thigh  ;  the  nature  of  these  layers  has  been  mentioned 
in  the  preceding  article.  We  will  only  remark,  that  the  sub-cutaneous 
cellulo-fatty  tissue  contains  all  the  nerves,  the  superficial  lymphatic 
vessels,  and  some  lymphatic  glands  superiorly ;  that  the  internal  saphe- 
na  vein  is  situated  internally  and  anteriorly  with  its  branches,  particu- 
larly with  that  which  comes  from  the  external  saphena ;  finally,  we 
must  not  forget,  that  among  these  different  sub-cutaneous,  nervous,  and 
vascular  ramifications  of  the  thigh,  the  nerves  proceed  from  above 
downward  and  perforate  the  aponeurosis  superiorly,  from  within  out- 
ward, and  proceed  into  the  layer  which  principally  belongs  to  them  ; 
while  the  lymphatic  vessels  and  the  veins  have  an  entirely  different 
course ;  they  ascend  and  penetrate  upward,  under  the  aponeurosis, 
through  special  openings. 

Below  the  fascia  lata  aponeurosis,  the  organic  layers  of  the  thigh 
are  not  so  distinctly  marked,  and  especially  they  are  not  common  to  its 
whole  circumference ;  hence,  the  relations  must  be  examined  succes- 
sively, anteriorly,  posteriorly,  externally,  and  internally. 

1.  Anteriorly,  the  relations  also  differ,  according  as  they  are  consi- 
dered superiorly  or  inferiorly.  Tn  the  first  point,  the  aponeurosis  being 
removed,  we  see  a  triangular  depression,  the  base  of  which  is  situated 
at  the  crural  arch,  and  its  summit  at  the  place  where  the  sartorius  and 
the  first  adductor  muscle  cross  ;  while  its  outer  edge  is  formed  by  the 
first  of  these  muscles,  and  the  internal  by  the  second ;  in  this  space, 
we  find  the  femoral  vessels,  in  the  course  of  a  line  drawn  from  its 
summit  to  its  base ;  these  vessels  are  arranged  in  such  a,  manner,  that 
the  vein  is  on  the  inside  superiorly,  and  then  glides  posteriorly ;  the 
trunk  of  the  crural  nerve  is  soon  divided  into  numerous  branches,  is 
contiguous  to  these  vessels  on  the  outside,  but  it  is  separated  from 
them  by  a  very  dense  fibrous  layer,  for  it  is  situated  in  the.  sheath  of 
the  psoas  muscle ;  while  the  artery  has  a  special  envelope,  which 


CRURAL  REGION.  317 

constitutes  the  crural  canal ;  two  of  the  branches  of  the  crural  nerve, 
however,  soon  come  into  the  sheath  of  the  vessels ;  before  them,  are 
the  two  roots  of  the  internal  saphena  nerve.     When  all  the  relations 
of  the  preceding  organs  have  been  examined,  and  we  have  removed 
the  sartorius  muscle  and  the  femoral  vessels,  with  the  parietes  of  their 
sheath,  we  find,  from  without  inward,  the  upper  extremity  of  the 
rectus  femoris  muscle  ;   the  end  of  the  psoas  and  iliacus  muscles, 
situated  in  their  sheath ;  the  interstice,  which  separates  this  muscular 
mass  from  the  pectineus  muscle,  and  in  which  the  internal  circumflex 
vessels  are  situated  ;  the  pectineus  muscle,  and  the  interstice  which 
separates  it  from  the  adductor  longus,  which  comes  next,  and  the  direc- 
tion of  which  is  crossed  by  the  passing  of  the  sub-aponeurotic  external 
genital  artery ;  below  the  rectus  femoris  muscle,  appear,  the  triceps, 
the  external  circumflex  vessels,  resting  on  the  neck  of  the  femur,  then 
a  portion  of  the  fibrous  capsule,  which  lies  under  the  pectineus  muscle, 
from  which  it  is  separated  by  a  mucous  bursa,  which  is  well  lubricated 
with  synovia ;  below  the  union  of  the  pectineus  and  the  adductor 
longus  muscle,  is  an  interstice,  where  we  find  the  obturator  vessels 
and  nerves,  and  to  which  the  obturator  externus  muscle  and  the  sub- 
pubic  foramen  correspond  above ;  more  deeply,  is  the  gracilis  muscle, 
on  the  inside,  the  adductor  brevis,  and  then  the  adductor  magnus, 
which  are  separated  by  a  branch  of  the  obturator  vessels  and  nerves. 
In  the  lower  half  of  the  thigh,  and  always  anteriorly,  we  find,  under 
the    aponeurosis,    the    rectus    femoris    muscle    anteriorly,    and    the 
sartorius,  which  proceeds  inward ;  we  find  below,  the  anterior  and 
internal  fasciculi  of  the  triceps  muscle,  the  inferior  part  of  the  adductor 
magnus  muscle,  and  an  aponeurotic  layer  which  goes  from  the  inner 
part  of  the  first  toward  the  second ;  this  layer  is  perforated  below  by 
a  large  cord  of  the  crural  nerve,  the  internal  saphena  nerve,  arid  rests 
directly  on  the  femoral  vessels,  which  are  ranged  so  that  the  vein  is 
entirely  posterior  to  the  artery,  and  they  correspond  to  the  deep  face 
of  the  sartorius  muscle,  being  situated  nearer  its  outer  than  its  inner 
edge.     Before  passing  through  the  preceding  aponeurosis,  the  saphena 
vein  is  contiguous  to  the  outer  and  anterior  side  of  the  femoral  vessels  ; 
finally,  all  these  parts  being  removed,  the  femur  is  seen  forward  and 
on  the  inside. 

2.  At  the  posterior  part  of  the  region,  and  under  the  aponeurosis, 
we  find  in  the  first  layer,  the  semi-tendinosus  muscle  and  the  long 
portion  of  the  biceps,  which  are  united  above,  and  separated  below  by 
an  angular  space,  the  commencement  of  the  popliteal  space;  more 
deeply,  we  find  the  semi-membranosus  muscle  alone  above,  below, 
also,  the  short  portion  of  the  biceps,  which  is  external,  while  the  first 
remains  on  the  inside  ;  more  deeply,  the  great  sciatic  nerve,  and  the 


318  TOPOGRAPHICAL  ANATOMY. 

posterior  arterial  chain,  formed  by  the  perforating  arteries  in  the  centre, 
the  articular  arteries  of  the  knee  below,  and  the  sciatic  artery  above, 
which  vessels  are  surrounded  with  some  very  loose  cellulo-fatty  tissue,' 
and  have,  with  the  buttock  above,  and  with  the  popliteal  space  below, 
the  relations  we  have  mentioned.  All  these  organs  being  removed, 
we  see  the  posterior  part  of  the  femur,  and  the  adductor  magnus  muscle, 
which  forms,  as  it  were,  a  septum,  between  the  posterior  and  internal 
faces  of  the  region. 

3.  On  the  outside,  below  the  aponeurosis,  we  find  directly  above, 
the  tensor  vaginae  femoris  muscle,  which  is  directed  posteriorly,  and 
below  which  the  external  circumflex  vessels  pass ;  below,  the  external 
portion  of  the  triceps,  which  is  situated  superiorly  under  the  first ;  and 
finally,  more  deeply,  the  external  part  of  the  femur. 

4.  On  the  inside,  the  relations  are  already  mentioned;  but  they 
were  considered  from  before  backward ;  we  will  consider  them,  also, 
from  without  inward,  from  the  skin  toward  .the  bone.     A  sub-aponeu- 
rotic  layer  is  formed  above  by  the  gracilis,  and  below  by  the  sartorius 
muscle,  which  crosses  the  former  ;  under  these,  and  at  the  upper  part, 
we  find  on  the  same  layer,  the  inner  edge  of  the  three  adductor  muscles, 
the  adductor  brevis  being  in  the  centre,  the  adductor  medius  anteriorly, 
and  the  adductor  longus  posteriorly;  the  adductor  brevis  separates 
the  other  two  only  on  the  upper  third  of  the  thigh,  and  the  adductor 
medius  does  not  descend  beyond  the  middle  third  of  the  same  region ; 
hence  it  follows,  that  the.  adductor  longus  alone  remains  at  the  lower 
part.     On  uniting  to  the. femur,  these  three  muscles  are  situated  in  an 
angle,  in  which,  in  the  centre  of  the  region,  we  find  the  femoral  vessels  ; 
if  we  penetrate  superiorly  into  the  two  interstices  formed  by  the  three 
adductor  muscles,  we  come  on  the  external  face  of  the  obturator  ex- 
ternus  muscle,  and  in  both  interstices  we  perceive,  as  we  have  already 
mentioned,  some  branches  of  the  sub-pubic  vessels  and  nerves,  and  of 
the  internal  circumflex  vessels ;  finally,  we  remark,  that  the  sub-pubic 
foramen  corresponds  to  the  most  anterior  interstice. 

These  are  the  relations  of  the  crural  region  ;  but  in  one  point  they 
must  be  studied  more  minutely.  This  is  in  the  upper  and  internal  part, 
where  the  sheath  of  the  femoral  vessels  becoming  broader,  communi- 
cates with  the  abdomen  in  the  groin,  and  constitutes  the  crural  canal. 

Crural  canal.  The  crural  canal,  the  upper  part  of  which  has 
already  been  mentioned,  is  a  triangular  space,  or  passage  for  the  crural 
vessels,  and  is  situated  at  the  upper  and  anterior  part  of  the  region  of 
the  thigh,  in  the  doubling  of  the  fascia  lata  aponeurosis.  Its  form  is 
evidently  triangular,  and  results  from  the  angular  union  of  the  pecti- 
neus  muscle  and  of  the  fasciculus  of  the  psoas  and  iliacus  muscles,  on 
which  it  rests. 


CRURAL  REGION.  319 

Its  direction  is  a  little  oblique  downward  and  inward;  we  do  not 
allude  here  to  the  direction  of  the  openings.  It  is  about  two  fingers' 
breadth  long,  and  is  a  little  more  extensive  outward  than  inward.  It 
is  broader  above  .than  below.  The  crural  canal  presents  a  central 
part  and  two  orifices  :  the  central  part  presents  three  parietes  :  one  of 
the  two  orifices  is  superior,  the  other  inferior. 

.1.  The  anterior  wall  of  the  crural  canal  is  thin,  particularly  on  the 
inside  ;  it  is  formed  by  the  anterior  fold  of  the  fascia  lata  aponeurosis, 
and  is  attached  to  the  crural  arch;  it  is  covered  by. some . lymphatic 
ganglions,  the  fascia  superficialis,  and  the  skin.  This  wall  presents 
several  openings,  through  which  pass  some  lymphatic  vessels,  which 
unite  the  superficial  and  deep  ganglions ;  one  of  these  ganglions  is 
sometimes  situated  in  one  of  the  openings. 

2.  The  external  wall  is  formed  by  the  deep  layer  of  the  femoral 
aponeurosis,  and  rests  on  the  psoas  and  iliacus  muscles;  the  "crural 
nerve  is  situated  on  the  outside  of  this  layer,  and  not  in  the  crural 
canal. 

3.  The  posterior  and  inferior  wall  is -formed  by  the  deep  layer  of 
the  fascia  lata  in  that  portion  resting  directly  on  the  pectineus  muscle. 

Three  angles  result  from  the  union  of  these  three  parietes  ;  one,  the 
posterior  and  external,  formed  by  the  union  of  these  last  two,  is  the 
only  one  which  is  important ;  it  contains  the  femoral  vessels  :  the 
other  two  are  less  interesting  ;  one  is  external,  the  other  is  internal. 

This  central  part  of  the  crural  canal  contains  the  femoral  vessels  in 
the  part  mentioned,  which,  vessels  are  arranged  so  that  the  vein  is 
internal.  We  also  ,find  there  a  dense  tissue,  interposed  between  the 
femoral  artery  and  vein,  and  a  lymphatic  ganglion,  situated  on  the 
inside  and  in  front  of  the  vein. 

The  upper  orifice  of  the  crural  canal  has  been  described,  the  inferior 
is  oval,  and  is  directed  inward  and  forward,  and  contains  the  internal 
saphena  vein,  to  which  it  is  evidently  destined  ;  its  circumference  is 
feeble  upward  and  inward  ;  on  the  contrary,  it  is  very  resisting  back- 
ward and  outward,  where  it  is  formed  by  a  fibrous  arch,  concave 
superiorly,  and  received  in  the  angle  formed  by  the  junction  of  the 
crural  and. internal  saphena  veins..  This  inferior  orifice  of  the  crural 
canal  is  also  continuous  below  with  the  rest  of  the  triangular  sheath 
of  the  femoral  vessels. 

The  crural  canal  is  a  little  longer  .in  the  male  than  in  the  female  ; 
in  return,  it  is  broader  in  the  latter.* 

*  We  can  trace  an  analogy  between  the  crural  canal  and  its  surrounding  parts,  and  the 
axilla  :  these  two  parts  are  situated  at  the  union  of  corresponding,  limbs  with  the  trunk,  have 
a  triangular  form,  contain  the  principal  vascular  branches  of  the  limb,  and  communicate  with 
the  trunk  by  a  triangular  opening. 


320  TOPOGRAPHICAL  ANATOMY. 

Development.  The  thigh  is  the  third  part  of  the  abdominal  limb, 
which  is  well  distinguished  in  the  fetus  ;  in  the  early  periods  of  life, 
it  is  remarkable  for  its  beauty,  its  roundness,  and  its  cylindrical  form  ; 
characters  which  depend  on  the  abundance  of  the  sub-cutaneous  fat 
in  the  limb,  and  also  on  the  slight  development  of  its  muscles  ;  in  the 
early  periods,  also,  the  central  bone,  the  femur,  is  slightly  arched 
anteriorly,  and  the  whole  thigh  participates  in  this  direction  ;  after  the 
period  of  puberty,  the  whole  region  becomes  convex  anteriorly,  and 
acquires  that  force  of  which  we  have  spoken.  Before  this  period,  the 
characters  of  the  thigh  present  no  sexual  varieties. 

Varieties.  In  the  female,  the  thigh  is  rounder,  whiter,  less  downy, 
and  proportionally  longer  than  in  the  male,  at  the  same  time  it  is  also 
larger,  especially  above,  on  account  of  the  superabundance  of  sub-cu- 
taneous fat ;  its  upper  extremity  is  separated  from  that  of  the  opposite 
side  by  a  space  which  is  greater,  on  account  of  the  greater  extent  of 
the  pelvis  on  which  it  rests  ;  it  follows,  also,  from  this  latter  arrange- 
ment, that  the  direction  of  the  thigh  in  the  female  is  more  oblique  than 
in  the  male. 

The  thigh  presents  numerous  individual  varieties  in  respect  to  size, 
length,  and  direction ;  in  some  males,  we  sometimes  find  all  the  cha- 
racters of  the  female. 

The  different  elements  of  the  thigh  also  present  several  varieties, 
which  must  be  carefully  mentioned,  as  some  of  them  are  extremely 
important  in  respect  to  operative  medicine.  The  pectineus  muscle  is 
sometimes  separated  into  two  fasciculi ;  this  is  true  also  of  the  three 
adductor  muscles ;  the  sartorius  is  often  interrupted  by  fibrous  inter- 
sections. Meckel  has  known  it  to  be  deficient,  and  sometimes  two  of 
them  to  exist.  The  biceps  may  present  a  supernumerary  fasciculus,  or 
may  have  but  one  fasciculus,  and  then  the  term  biceps  is  misapplied. 
The  femoral  artery,  instead  of  giving  off  its  deep  branch  an  inch'  and  a 
half  below  the  crural  arch,  may  divide  much  higher  than  usual,  as  at 
this  part,  or  even  unusually  low.  We  have  seen  very  recently  the  deep 
femoral  artery  arise  in  the  centre  of  the  thigh.  The  sciatic  nerve 
sometimes  divides  very  high  posteriorly,  and  even  at  its  origin. 

Uses.  The  thigh  plays  a  very  important  part  in  standing ;  it  sus- 
tains directly  the  weight  of  the  trunk,  as  the  haunch  is  almost  entirely 
blended  with  this  latter  ;  it  is  balanced  between  the  anterior  and  pos- 
terior muscles,  each  of  which  solicits  it  in  their  direction.  Its  internal 
muscles  cause  in  it  the  motion  of  adduction  ;  the  motion  of  abduction 
is  less  powerful. 

Pathological  and  operative  deductions.  Wounds  of  the  anterior 
and  superior  parts  of  the  thigh,  and  those  of  its  internal  and  central 
part,  may  be  very  serious,  and  sometimes  even  fatal.  The  femoral 


CRURAL  REGION.  321 

artery  may  easily  be  injured  in  these  different  points.  Upward  and 
forward,  however,  this  vessel  is  more  particularly  exposed  to  wounding 
instruments,  on  account  of  its  superficial  position  ;  in  this  place,  also, 
it  has  been  opened  by  certain  individuals  in  order  to  commit  suicide. 
The  juxta-position  and  intimate  union  of  the  femoral  artery  and  vein 
show  the  possibility  of  their  being  injured  simultaneously  by  a  pricking 
instrument,  and  also  of  the  occurrence  of  a  particular  species  of  aneu- 
rism, the  varicose,  a  species  which  is  almost  the  necessary  consequence 
of  it :  all  the  circumstances  favorable  to  the  formation  of  this  disease, 
appear  in  this  region,  hence  the  disease  has  been  frequently  seen  here. 
The  femoral  artery,  and  its  attendant  vein,  are  easily  wounded  simul- 
taneously, below  the  upper  third  of  the  thigh,  by  a  stylet  carried 
directly  from  before  backward,  or  in  an  opposite  direction.  Above  this 
point,  an  instrument,  to  produce  the  same  effect,  must  act  transversely, 
or,  at  least,  obliquely,  from  without  inward,  and  from  before  backward ; 
anatomy  accounts  for  these  phenomena,  since  in  the  first  point  the 
artery  is  anterior  to  the  vein,  while  in  the  second,  these  two  vessels 
are  situated  side  by  side,  the  vein  on  the  inside  of  the  artery.  The 
other  varieties  of  aneurisms,  besides  varicose  aneurism;  may  appear  in 
the  thigh.  In  this  case,  or  when  we  wish  to  arrest  a  hemorrhage 
coming  from  the  principal  arterial  trunk  of  the  thigh,  which  is  wound- 
ed, we  may  be  obliged  to  tie  it ;  this  operation,  also,  is  indicated  for  the 
cure  of  aneurism,  or  for  certain  wounds  of  the  arteries  of  the  leg,  as 
we  shall  mention  hereafter.  The  artery  may  be  tied  at  different  points, 
which  generally  depend  on  the  part  affected ;  when,  however,  a  disease  of 
the  arteries  of  the  leg  or  knee  is  to  be  treated,  the  place  may  be  selected 
by  the  surgeon.  If  we  wish  to  tie  the  femoral  artery  when  it  enters  the 
canal  of  the  third  adductor  muscle,  as  Hunter  advises,-  we  must  remem- 
ber, that  anteriorly  it  is  covered  in  this  point  by  the  sartorius  muscle, 
being  situated  near  its  outer  edge,  and  that  directly  before  it  an  aponeu- 
rotic  layer  exists,  which  goes  from  the  vastus  internus  to  the  adductor 
magnus  muscle  ;  if  we  then  follow  these  anatomical  relations,  and  cut 
along  the  outer  edge  of  the  sartorius  muscle,  we  divide  successively; 
the  skin,  the  sub-cutaneous  cellular  tissue;  we  leave  on  the  inside^  the 
internal  saphena  vein ;  we  also  cut  the  fascia  lata  aponeurosis ;  we  next 
turn  to  the  inside  the  sartorius  muscle,  and  come  into  its  sheath  ;*  we 
then  divide  on  a  director  the  aponeurosis  which  immediately  covers 
the  artery,  and  we  raise  this  from  without  inward,  avoiding  on  the 
outside,  the  internal  saphena  nerve  and  the  femoral  vein  posteriorly* 

*  If  we  do  not  cut  exactly  in  the  direction  of  the  sartorius  muscle,  we  open  the  sheath  of 
the  triceps  anteriorly,  and  it  is  difficult  to  find  the  artery.     The  outer  edge  of  the  sartorius  is 
indicated  by  a  line  drawn  from  the  anterior  and  superior  spine  of  the  ilium,  to .  the  postemrf 
part  of  the  inner  condyle  of  the  femur. 
41 


322  TOPOGRAPHICAL    ANATOMY. 

If,  on  the  contrary,  as  Scarpa  prefers,  we  wish  to  tie  the  artery,  at  the 
base  of  the  groin,  it  is  situated  in  this  part  more  superficially ;  in 
order  to  come  to  it,  we  have  only  to  divide  the  skin  and  the  femoral 
aponeurosis,  along  the  internal  edge  of  the  biceps,  and  we  then  find  it 
in  relation,  posteriorly  and  internally,  with  its  attendant  vein,  which  is 
contiguous  to  the  two  cords  of  the  crural  nerve  which  contribute  to 
form  the  internal  saphena  nerve ;  it  must  be  raised  from  within  out- 
ward to  avoid  the  vein  which  is  found  in  this  direction.  If  we  wish 
to  arrive  at  the  femoral  artery  in  the  middle  of  this  region,  we  may 
either  raise  the  sartorius  from  within  outward,  or  from  without  inward, 
as  the  artery  is  situated  at  an  equal  distance  from  both  edges.  Ope- 
rators do  not  agree  on  the  place  to  tie  the  femoral  artery  for  aneurisms, 
when  the  place  is  to  be  selected ;  let  us  examine  each  process  in  an 
anatomical  point  of  view.  Hunter's  operation  is  more  difficult  than 
that  of  Scarpa,  but  it  has  the  advantage  of  placing  the  ligature  farther 
from  the  deep  femoral  artery  ;  this  circumstance  is  of  advantage,  as  no 
hemorrhage  follows  when  the  ligature  is  removed  ;  but,  on  the  other 
hand,  it  exposes  perhaps  to  hemorrhage  by  dividing  the  artery  too 
soon,  because  the  ligature  is  applied  nearer  the  part  where  the  artery 
is  aneurismatic,  and  consequently  more  or  less  diseased  ;  hence,  it  is 
clear,  that  the  two  processes  have  advantages  and  disadvantages, 
which  balance  each  other.  As,  however,  these  processes  differ  in  re- 
spect to  the  place  where  the  ligature  is  applied  to  the  artery,  and  also, 
as  the  points  of  the  femoral  artery,  which  are  tied  in  these  two  cases, 
are  situated  opposite  to  each  other,  we  may  perhaps  select  an  interme- 
diate process  which  would  combine  the  advantages  of  the  two  methods  ; 
this,  in  fact,  is  obtained,  by  tying  the  femoral  artery  in  the  middle  of 
the  thigh  ;  in  fact,  there,  it  is  farther  from  the  deep  artery  and  from  the 
part  where  the  artery  is  affected,  than  in  Scarpa's  or  Hunter's  process. 
Farther,  we  have  mentioned  some  cases  where  the  deep  femoral  artery 
arose  lower  than  usual ;  in  an  individual  presenting  this  variety,  if  the 
ligature  had  been  applied  according  to  Scarpa's  process,  the  artery 
would  have  been  tied  above  the  deep  femoral  artery,  or  which  would 
have  been  still  worse,  in  regard  to  consecutive  hemorrhage,  directly 
below  it.  In  aneurisms  of  the  highest  part  of  the  femoral  artery,  the 
external  iliac  artery  must  be  tied  as  we  have  stated ;  but  when  the 
tumor  is  developed  below  the  deep  artery,  and  very  near  it,  must  we,  to 
avoid  this  collateral  artery,  apply  the  ligature  directly  above  the  tumor, 
or  tie  also  the  external  iliac  artery  ?  Roux  has  very  recently  proved, 
by  experiment,  that  it  may  be  tied  below  the  deep  artery.  We  must, 
however,  state,  that  in  applying  the  ligature  directly  below  so  large  a 
collateral  branch,  the  patient  is  exposed  to  consecutive  hemorrhage ; 
but  we  must  not  think,  however,  that  this  is  so  much  to  be  feared,  as 


CRURAL  REGION.  323 

in  those  cases  where  the  external  iliac  artery  has  been  tied  below  the 
epigastric  artery  ;  in  fact,  in  this  latter,  all  the  weight  of  the  column 
of  blood  sent  by  the  heart  into  the  artery  is  supported  by  the  cicatrix, 
and  but  little  of  this  fluid  passes  through  the  epigastric  and  circumflex 
iliac  arteries :  on  the  contrary,  where  the  femoral  artery  is  tied  directly 
below  the  deep  femoral  artery,  the  arterial  cicatrix  sustains  the  weight 
of  a  much  smaller  column  of  blood,  as  the  circulation  is  promptly  and 
easily  re-established  by  the  deep  femoral  artery,  which  almost  corre- 
sponds, in  its  size  and  direction,  to  the  vessel  which  has  been  tied. 
This  is  undoubtedly  the  reason  why,  in  these  ligatures  of  the  femoral 
artery,  hemorrhages  are  less  frequent  than  they  would  seem  to  be  at 
first  view  ;  this  exception  to  the  general  rule,  to  tie  an  artery  as  far  as 
possible  below  a  large  collateral  artery,  can  be  easily  explained  by 
anatomy,  and  must  also  modify  the  precept  in  regard  to  the  proper 
place  for  applying  ligatures  to  the  large  arteries  ;  viz.  to  apply  the  liga- 
ture as  far  as  possible  from  the  great  superior  collateral  arteries,  espe- 
cially when,  by  their  size  and  direction,  they  vary  much  from  the 
principal  trunk.  When  the  femoral  artery  has  been  tied  above,  the 
circulation  is  re-established  by  means  of  the  anastomoses  of  the  circum- 
flex arteries  with  the  obturator,  the  gluteal,  and  the  sciatic  arteries,  and 
of  these  latter  with  the  perforating  arteries.  These  communications, 
particularly  those  of  the  obturator  with  the  internal  circumflex  artery, 
are  sufficient  in  the  cadaver,  when  the  femoral  artery  has  been  tied 
above,  to  carry  even  a  coarse  injection  from  the  primitive  iliac  artery 
into  the  whole  thigh ;  ought  theyvnot  then  to  be  sufficient  to  give  pas- 
sage to  the  blood,  which  is  remarkably  thin  ?  The  deep  femoral  artery 
then  receives  the  blood  directly,  and  carries  it  into  the  lower  part  of 
the  femoral  trunk  which  has  been  obliterated  above.  If,  on  the  con- 
trary, the  ligature  has  been  passed  below  the  great  collateral  artery 
mentioned,  the  blood  is  distributed  into  the  whole  posterior  arterial 
system  of  the  thigh,  dilates  the  anastomoses  of  the  perforating  arteries, 
and,  following  their  chain,  comes  into  the  popliteal  trunk.  We  can 
then  conceive  the  immense  importance  of  the  anastomotic  chain  of  the 
preceding  arteries,  which  form,  in  some  measure,  a  supplementary  canal, 
which  is  designed  to  re-establish  the  circulation  between  the  upper  and 
lower  parts  of  the  region  of  which  we  are  speaking.  In  deep  inflam- 
mations of  the  thigh,  deep  incisions  are  more  necessary  than  in  any 
other  part,  because  its  aponeurosis  is  more  resisting  there  than  any 
where  else.  The  numerous  sheaths  which  this  fibrous  layer  forms  for  the 
muscles,  explain  the  constant  direction  in  which  effusions  of  blood  or 
pus  extend  in  this  region;  in  fact,  are  they  situated  in  the  posterior 
part  of  the  thigh,  in  the  sheath  of  the  posterior  muscles?  They  bur- 
row downward  toward  the  popliteal  space,  or  upward  toward  the 


324  TOPOGRAPHICAL  ANATOMY. 

buttock,  the  sciatic  foramina,  and  even  the  pelvis,  as  we  have  said 
above.    On  the  contrary,  are  they  situated  anteriorly,  in  the  sheath  of 
the  triceps  ?     They  re- ascend  or  descend,  separating  the  femur  from 
the  muscles  which  are  attached  to  it.     Those  which  form  in  the 
sheaths  of  the  adductor  muscles,  may  also  go  superiorly  to  the  pelvis 
and  pass  into  the  intra-pelvic  region  through  the  sub-pubic  foramen  ; 
finally,  we  have  spoken  of  deep  abscesses  of  the  internal  iliac  fossa, 
and  of  their  burrowing  towards  the  small  trochanter.    The  facility  with 
which  pus  or  blood  burrow  in  the  aponeurotic  sheaths  of  the  muscles 
of  the  thigh,  has  often  prevented  the  cure  of  those  in  whom  the  thigh 
had  been  amputated ;  hence,  in  these  cases,  we  must  facilitate  the  dis- 
charge of  pus  as  much  as  possible,  either  by  compressing  the  stump 
by  an  elastic  bandage  above  the  wound,  or  by  uniting  this  loosely, 
giving  to  it  a  sloping  position.     In  no  part  are  the  two  muscular  layers 
more  distinct,  than  in  the  thigh  ;  in  no  part,  also,  are  the  precepts  of 
Chiselden  .and  J.  L.  Petit,  in  respect  to  amputations,  more  applicable, 
and  at  the  same  time  more  necessary.     The  form  of  a  reversed  cone, 
presented  by  the  crural  region,  has  given  rise  to  the  excellent  precept 
to  amputate  it  as  low  as  possible,  in  order  to  have  a  smaller  bleeding 
surface.     In  this  operation  we  have  always  to  tie  the  femoral  artery, 
twhich  is  situated  on  the  inside  of  the  bone,  the  deep  femoral  artery, 
which  is  a  little  posterior,  and  several  muscular  arteries,  which  are 
situated  on  the  inside,  backward  and  outward.     The  flap  operation 
should  always  be  performed,  so  as  to  have  an  external  and  an  internal 
flap.     This  course  is  founded  on  two  anatomical  reasons  ;  first,  be- 
cause the  vascular  trunks  are  situated  in  one  of  the  flaps,  the  internal ; 
second,  because  the  large  muscles  are  placed  on  the  sides  of  the  region. 
Farther,  after  this  flap  operation,  the  femur  often  projects  in  the  ante- 
rior angle  of  their  union :  this  is  readily  admitted,  when  we  reflect 
that  on  this  side  it  is  situated  naturally  very  near  the  external  surface. 
To  avoid  this  projection  of  the  bone,  it  has  been  proposed  to  make  an 
anterior  and  also  a  posterior  flap ;  but  this  operation  presents  incon- 
veniences, which  it  is  unnecessary  to  mention,  after  what  we  have 
stated  above.     The  thigh  has  been  extirpated  several  times  success- 
fully.    To  perform  it,  we  must  remember  that  the  coxo-femoral  articu- 
lation is  situated  three  fingers'  breadth  below  the  anterior  and  superior 
spine  of  the  ilium,  and  that  the  femoral  vessels  are  situated  there  ante- 
riorly in  the  crural  canal.     Then,  whatever  may  be  the  process  fol- 
lowed in  the  formation  of  the  flaps,  whether  we  commence  by  the 
external  or  by  the  internal,  and  form  both  of  them  before  opening  the 
articulation,  or  whether  we  first  form  one  of  the  flaps,  and  then  open 
the  articulation  directly,  to  terminate  by  the  opposite  flap,  we  must 
never  forget,  that  the  quickest  mode  of  disarticulating  the  limb  is  to 


CRURAL  REGION.  325 

divide  the  fibrous  capsule  very  high  on  the  head  of  the  femur. 
Beclard  advises  us,  in  performing  this  operation,  to  make  two  flaps,  an 
anterior,  and  a  posterior  ;  this  method  is  advantageous,  as  it  leaves  the 
principal  artery  in  one  of  the  flaps,  the  anterior,  and  may  be  performed 
very  quickly ;  for  when  the  anterior  flap  is  once  made,  the  whole  ante- 
rior part  of  the  fibrous  capsule  is  exposed,  and  is  readily  divided. 
However,  in  whatever  mode  this  operation  is  performed,  it  is  terrific, 
both  for  its  immediate  results  and  for  the  dangers  with  which  it  is 
attended,  on  account  of  its  proximity  to  the  trunk ;  it  should  therefore 
be  considered  as  the  last  resource  of  art ;  when,  however,  it  is  indicated, 
it  seems  to  us  prudent  to  tie  the  femoral  artery  below  the  crural  arch, 
before  commencing  it ;  we  thus  avoid  severe  hemorrhage  during  the 
operation.  The  wound  made  in  tying  the  femoral  artery  may  serve 
as  the  commencement  of  the  incision  ;  it  is  consequently  incorrect  to 
say,  that  the  patient  is  thus  subjected  to  two  operations. 

We  have  spoken  above  of  the  different  engorgements  of  the  inguinal 
ganglions  and  of  femoral  hernia  ;  we  have  considered  the  latter,  how- 
ever, only  in  regard  to  its  neck,  or  upper  orifice ;  we  will  now  examine 
it  in  respect  to  the  lower,  or  to  the  crural  canal.  The  tumor  which 
forms  it,  glides  forward  and  on  the  inside  of  the  femoral  vessels,  and 
descends  into  the  crural  canal,  raising  its  anterior  wall ;  while  it  con- 
tinues in  this  point,  it  is  very  small,  but  afterward,  it  always  leaves 
the  crural  canal,  frequently  by  one  of  the  openings  in  its  anterior  wall ; 
sometimes,  it  passes  through  the  opening  of  the  saphena  vein,  which 
terminates  this  passage  inferiorly ;  finally,  Cloquet  has  seen  the  tumor 
of  crural  hernia  descend  beyond  the  crural  canal  in  the  sheath  of  the 
femoral  vessels.  In  this  latter  case,  the  base  of  the  tumor  looks  down- 
ward ;  it  is  directed  forward  in  the  others,  which  gives  the  whole 
tumor  a  curved  direction,  concave  superiorly,  so  that  it  seems  to  em- 
brace the  crural  arch.  The  crural  hernia,  if  it  leaves  the  crural  canal, 
is  covered  by  the  skin,  the  fascia  superficialis,  in  which  the  vessels  of 
the  integuments  of  the  abdomen  and  the  superficial  external  genital 
vessels  are  situated,  and  finally,  by  the  peritoneum ;  in  the  opposite 
case,  the  anterior  wall  of  this  passage  is  situated  farther  in  front  of  it. 
We  thus  see  that  crural  hernia  is  situated  more  superficially  than 
inguinal,  and  particularly  than  external  inguinal  hernia.  The  pus  of 
certain  congested  abscesses,  which  have  been  mentioned  above,  also 
burrow  into  the  crural  canal,  before  the  vessels  of  the  thigh,  conse- 
quently in  the  place  occupied  by  the  hernia  :  it  is  hardly  necessary  to 
remark,  that  these  abscesses  pulsate,  hence  they  have  sometimes  been 
considered  as  aneurismal  tumors.  Hernia  of  the  sub-pelvic  foramen, 
which  we  have  mentioned  in  regard  to  its  neck  and  the  opening 
through  which  it  passes,  is  situated  at  the  upper  and  inner  part  of  the 


326  TOPOGRAPHICAL  ANATOMY. 

thigh,  between  the  adductor  longus,  the  pectineus,  and  the  adductor 
magnus  muscles,  leaving  the  obturator  vessels  behind  it.  H.  Cloquet 
has  described  the  mode  of  operating  when  it  is  strangulated  ;  we  have 
also  stated  the  manner  of  dividing  the  strangulating  part :  in  order  to 
expose  it,  we  must  cut  in  the  course  of  a  line  drawn  from  the  spine  of 
the  pubis  to  the  union  of  the  upper  third  with  the  two  lower  thirds  of 
the  thigh  ;  and  after  dividing  the  skin,  the  sub-cutaneous  cellulo-fatty 
tissue,  and  one  of  the  genital  arteries  which  passes  through  the  fascia 
lata  aponeurosis,  and  the  deep  genital  artery  which  it  covers,  we  see 
the  cellular  interstice  of  the  pectineus  and  of  the  adductor  longus 
muscle ;  we  separate  these  two  muscles,  and  the  tumor  then  appears  in 
the  place  mentioned. 

It  is  only  in  dislocations  of  the  femur  downward  and  inward,  that 
the  tumor  formed  by  the  head  of  the  femur,  remains  at  the  inner  part 
of  the  thigh,  on  the  outer  part  of  the  sub-pubic  foramen.  In  these 
cases,  this  bony  head  is  always  covered  by  the  pectineus  muscle. 
When  the  femur  is  fractured  directly  below  the  small  trochanter,  the 
upper  fragment  is  drawn  upward  and  inward  by  the  psoas  and  iliacus 
muscles,  and  the  inferior  is  drawn  outward  by  the  rectus  femoris, 
biceps,  &c.  If  the  fracture  occurs  in  the  centre  of  the  thigh,  the  pos- 
terior muscles  bring  together,  posteriorly,  the  two  extremities  of  the 
arch  of  the  femur,  between  which  they  are  naturally  extended,  and 
hence  a  projection  of  the  two  fragments  anteriorly,  which  it  is  often 
very  difficult  to  overcome,  even  with  the  greatest  care.  The  femur  is 
often  affected  with  necrosis;  in  this  disease,  when  we  wish  to  make 
incisions  to  find  the  sequestra,  they  should  always  be  cut  on  the  out- 
side, because  this  is  the  least  vascular  part  of  the  region,  and  where 
the  bone  is  situated  most  superficially. 


2.       OF       THE       KNEE. 

The  knee  is  the  angle  of  union  of  the  thigh  and  leg  ;  its  limits  are 
formed  artificially  four  fingers'  breadth  above  and  below  the  patella. 

The  angle  of  the  knee  is  open  posteriorly,  and  projects  anteriorly, 
particularly  when  the  leg  is  slightly  flexed ;  in  extension,  it  almost 
disappears.  This  region  is  prominent  inward  and  forward  ;  it  is  de- 
pressed, on  the  contrary,  outward  and  backward.  Externally,  it  pre- 
sents ;  anteriorly,  the  prominence  of  the  patella,  bounded  laterally  by 
two  depressions,  the  internal  of  which  is  the  larger ;  posteriorly,  a 
median  depression,  elongated  from  above  downward,  and  terminated 
laterally  by  some  muscular  prominences,  which  are  very  distinct  when 
the  leg  is  flexed  ;  on  the  outside,  two  tuberosities,  situated  on  the  same 

• 


KNEE.  327 

vertical  plane,  one  belonging  to  the  external  condyle  of  the  femur,  the 
other  to  the  head  of  the  fibula ;  on  the  inside,  only  one  eminence,  that 
of  the  internal  condyle,  which  is  larger,  and  conceals  the  corresponding 
tuberosity  of  the  tibia. 

Structure. — 1.  Elements.  The  skeleton  of  the  knee  is  formed  by 
all  the  elements  of  the  femoro-tibial  articulation  :  first  the  two  con- 
dyles  of  the  femur,  separated  anteriorly  by  a  pulley,  the  cavity  of  which 
is  not  very  deep,  and  the  external  plane  is  the  most  extensive  ;  second, 
the  two  superior  cavities  of  the  tibia,  the  depth  of  which  is  increased 
by  the  two  semi-lunar  fibro-cartilages  which  are  situated  on  their 
edges ;  third,  finally,  the  patella,  the  posterior  face  of  which  is  smooth, 
and  presents  a  blunt  ridge,  from  which  two  smooth  surfaces  pro- 
ceed obliquely,  of  which  the  .external  is  the  most  extensive  ;  this  arti- 
culation is  formed  by  two  very  firm  lateral  ligaments,  by  a  posterior 
membranous  ligament,  formed  in  part  by  the  tendon  of  the  semi- 
membranosus  muscle,  by  an  anterior  ligament,  termed  that  of  the 
patella,  but  which  is  only  accessory  to  the  femoro-tibial  articulation, 
as  it  is  in  fact  the  end  of  the  tendon  of  the  extensor  muscles  of  the  leg, 
in  which  the  patella  is  situated ;  finally,  by  two  inter-articular  ligaments, 
termed  the  crucial.  The  membrane  which  lubricates  this  articulation 
is  very  extensive  and  moist :  it  forms  a  great  number  of  folds,  like 
fringes  ;  first,  anteriorly,  behind  the  patella  and  its  ligament ;  second, 
posteriorly,  on  the  crucial  ligaments.  The  pretended  adipose  ligament 
of  some  authors  is  only  a  synovial  band  of  the  same  kind.  Two  or 
three  muscular  fasciculi  come  from  the  femur,  and  form  the  sub- 
cruralis  muscle  of  Meckel,  which  is  inserted  on  the  upper  part  of  this 
synovial  pouch,  and  form,  with  the  popliteus,  the  only  special  muscles 
of  this  region,  in  which,  however,  many  terminate  or  arise.  Among 
the  former,  are  the  triceps,  the  biceps,  the  adductor  longus,  the  semi- 
membranosus,.  and  finally,  the  semi-tendinosus,  the  gracilis,  and  the 
sartorius  muscles,  which  unite  at  the  base  of  the  knee,  and  form  toge- 
ther what  is  improperly  termed  the  pes  anseris  ;  the  muscles  which 
arise  there  are  less  numerous,  and  are  only  the  gastrocnemius  and  the 
plantaris. 

The  aponeurosis  of  the  abdominal  limb  is  extremely  complex  in  the 
knee  ;  it  has  been  wrongly  represented  as  attached  on  its  sides  to  the 
condyles  of  the  femur  and  to  the  tuberosities  of  the  tibia  ;  below,  it  is 
strengthened  by  some  fibrous  expansions  detached  from  the  triceps, 
the  biceps,  the  sartorius,  the  gracilis,  the  semi-tendinosus,  and  the 
semi-membranosus  ;  it  sends  off  above  from  its  internal  face,  a  fibrous 
septum  to  each  of  the  edges  of  the  femur,  which  arrangement  forms 
in  the  knee  two  principal  sheaths,  continuous  with  those  of  the  thigh, 
an  anterior  and  a  posterior ;  the  first  is  the  end  of  that  of  the  triceps, 


328  TOPOGRAPHICAL    ANATOMY. 

the  second  continues  the  posterior  sheath  of  the  thigh ;  the  sheaths  oi 
the  sartorius  and  gracilis  muscles  also  extend  on  the  inside  of  this 
region  ;  finally,  a  last  deep  layer  is  sent  by  the  aponeurosis  of  the 
knee  on  the  popliteus  muscle.  The  popliteal  artery,  the  last  section 
of  the  general  arterial  trunk  of  the  limb,  belongs  almost  entirely  to  the 
knee  ;  it  presents  there  one  or  two  slight  external  sinuosities,  and  some 
transverse  folds,  which  belong  particularly  to  its  internal  membrane. 
This  artery,  however,  merely  passes  through  the  knee,  giving  off  to 
it  its  nutritive  vessels,  among  which  we  mention,  particularly,  the 
articular  arteries,  which  are  at  least  five  in  number ;  two  of  these  are 
superior,  and  proceed  above  the  condyles  to  the  anterior  face  of  the 
region  ;  two  are  inferior,  and  also  go  to  the  same  point,  below  the 
tuberosities  of  the  tibia  ;  the  last  penetrate  into  the  posterior  part  of  the 
articulation.  A  sixth  artery  of  the  knee  retrogrades  from  the  anterior 
tibial  artery ;  it  is  the  recurrent  tibial  artery.  The  arrangement  of 
these  arteries  in  this  region  is  remarkable  ;  being  united  sometimes  by 
transverse  and  vertical  arches,  and  sometimes  by  a  very  complex 
plexus,  they  establish  collateral  passages,  which  are  always  open  for 
the  circulation  between  the  upper  part  of  the  popliteal  artery  and  the 
anterior  tibial  artery.  We  add,  as  has  already  been  ^observed,  that  the 
last  perforating  arteries  also  unite  to  the  superior  articular  arteries, 
and  we  shall  see  that  the  limits  of  these  eccentric  canals,  by  which  the 
anterior  tibial  artery  may  receive  the  blood,  in  certain  cases  extend 
still  higher,  and  even  into  the  pelvis.  In  the  region  of  the  knee,  the 
popliteal  artery  also  gives  off  some  large  branches  to  the  muscles,  par- 
ticularly to  the  gastrocnemius  and  the  soleus.  All  the  veins  accom- 
pany the  arteries,  and  have  generally  the  same  arrangement  with  them, 
except  the  internal  and  external  saphena  veins,  the  first  of  which  only 
passes  through  the  region,  while  the  second  partially  terminates  in  it, 
sending  also  a  branch  toward  the  thigh  In  this  region,  also,  there  are 
generally  found  three  lymphatic  ganglions,  all  of  which  are  situated 
posteriorly  in  the  popliteal  space ;  they  receive  the  deep  lymphatic 
vessels  of  the  leg  and  knee,  while  the  superficial  lymphatic  vessels  go 
to  the  superficial  inguinal  ganglions.  The  nerves  of  the  knee,  like 
those  of  the  thigh,  come  anteriorly,  and  on  the  sides  from  the  lumbar 
plexus,  posteriorly  from  the  sacral  plexus.  The  first  proceed  from  the 
inguino-cutaneous,  the  genito-crural,  and  the  crural  nerves ;  the  second 
from  the  small  sciatic  nerve,  and  also  from  the  great  sciatic  nerve, 
which  passes  deeply  through  this  point,  and  divides  into  two  principal 
branches,  the  external  and  internal  popliteal,  from  which  the  internal 
saphena  nerve  proceeds  by  two  roots,  which  present  numerous  varieties. 
Two  twigs  of  the  crural  nerve  extend  into  this  region,  after  following 
for  a  long  time  the  crural  artery,  and  unite  to  form  the  internal  saphena 


KNEE.  329 

nerve,  which  also  rises,  as  we  see,  by  two  roots,  which  no  author  has 
as  yet  observed.  The  cellular  tissue  of  the  knee  is  more  abund.ant 
posteriorly  than  in  any  other  point,  and  it  is  also  a  little  looser  there. 
Fat  appears  there  in  small  quantity,  except  in  certain  points  ;  as,  for 
instance,  under  the  aponeurosis,  below  the  triceps,  at  the  upper  part 
of  the  synovial  pouch  of  the  knee  ;  behind  the  ligament  of  the  patella, 
where  it  forms  a  considerable  body ;  finally,  between  the  posterior 
ligament  and  the  crucial  ligaments.  Three  very  thin  mucous  bursse 
also  are  constantly  found  in  the  knee,  one  between  the  skin  and  the 
patella,  another  between  the  lower  extremity  of  the  ligament  of  the 
patella  and  the  thin  part  of  the  tibia,  the  last  between  the  inner  head 
of  the  gastrocnemius  and  the  semi-membranosus  muscles. 

2.  Relations.     The  relations  of  the  knee  are  very  important,  and 
slightly  complex  ;  the  skin,  the  sub-cutaneous  cellulo-fatty  tissue,  and 
the  aponeurosis,  envelope  it  uniformly  in  every  part,  and  successively, 
from  without  inward,  in  very  distinct  layers  ;  the  second,  however,  is 
thinner  anteriorly  and  laterally  than  posteriorly,  where  also  it  is  almost 
entirely  fatty  ;  it  contains  in  its  areolas  the  veins,  the  lymphatic  vessels; 
the  superficial  nerves,  and  particularly,  on  the  inside,  the  internal 
saphena  vein,  and  posteriorly,  the  ascending  branch  of  the  external 
saphena  vein'.     The  aponeutosis  being  removed,  we  find  no  general 
layer  ;  hence  the  relations  must  be  studied  in  another  manner.     Under 
the  aponeurosis  we  penetrate  forward  and  outward,  into  the  sheath  of 
the  triceps,  where  we  generally  find,  anteriorly  and  at  the  patella,  & 
mucous  bursa,  which  is  wrongly  regarded  as  sub-cutaneous ;  in  other 
cases,  a  lamellar  cellular  tissue,  in  which  is  an  arterial  plexus  ;  then, 
on  the  same  plane,  the  end  of  the  triceps  above,  the  patella  in  the 
centre,  and  below,  the  ligament  of  the  patella  and  art  expansion  Which 
the  triceps  sends  forward,  on  the  sides  of,  and  below  the  patella,  .which 
expansion  is  soon  blended  with  the  aponeurosis  ;  behind  the  ligament 
of  the  patella,  a  mucous  biirsa  exists  below,  while  above,  a  considerable 
adipose  body  separates  it  from  the  articular  synovial  membrane  ;  the 
latter,  on  the  contrary,  is  directly  in  relation  with  the  posterior  face  of 
the  patella  and  the  end  of  the  triceps,  under  which  it  is  reflected, 
forming  a  cul-de-sac,  in  which  the  fasciculi  of  the  small  levator  muscle 
of  the  synovial  capsule,  the  sUb-cruralis,  are  attached.     Below  the 
triceps,  we  also  find  the  transverse  branch  of  the  superior  articular 
arteries,  and  a  loose  cellulo-fatty  layer,  in  which  the  patella  sometimes 
ascends,  and  the  synovial  capsule  of  the  articulation:     On  the  sides 
of  the  knee,  we  also  come,  as  has  been  said,  into  the  sheath  of  the 
triceps,  which  is  terminated  above  the  condyles  of  the  femur  on  each 
side,  by  strong  fibrous  fasciculi,  under  which  pass  the  superior  articular 
arteries  ;  the  internal  of  these  fasciculi  is  formed  mostly  by  the  tendorf 

42 


330  TOPOGRAPHICAL    ANATOMY. 

of  the  adductor  magnus  muscle.     Farther,  in  this  sheath,  we  find  only 
the  condyles  of  the  femur,  the  tuberosities  of  the  tibia,  the  lateral  liga- 
ments, under  which  pass  the  inferior  articular  vessels,  and  under  the 
external,  in  particular,  the  tendon  of  the  popliteus  muscle.     On  the 
inside  and  posteriorly,  out  of  the  sheath  of  the  triceps,  we  find,  on  the 
same  plane,  the  sartorius  and  gracilis  muscles,  each  situated  in  its 
sheath ;  the  sheath  of  the  sartorius  is  more  internal  than  the  other, 
and  also  contains  deeply  the  two  roots  of  the  internal  saphena  nerve. 
The  posterior  cutaneous  nerve  of  the  thigh  descends  posteriorly  be- 
tween the  layers  of  the  aponeurosis,  and  in  a  small  separate  sheath, 
accompanied  by  a  vein,  which  goes  into  the  external  saphena  vein ; 
then  we  see  this  vein,  and  one  of  the  roots  of  its  nerve,  which  presents 
varieties  to  be  mentioned  when  speaking  of  the  leg.     More  deeply,  is 
an  oblong  space,  circumscribed  by  masses  of  muscles ;  this  is  the  po- 
pliteal space,  formed  outward  and  upward  by  the  biceps,  outward  and 
downward  by  the  external  head  of  the  gastrocnemius,  the  plantaris 
embraced  by  the  first,  and  the  condyle  of  the  femur  concealed  by  both, 
inward  and  upward  by  the  semi-tendinosus,  the  semi-membranosus, 
the  first  of  which  is  the  more  superficial,  inward  and  downward  by 
the  inner  head  of  the  gastrocnemius,  embraced  by  the  two  preceding 
muscles,  then  by  the  internal  condyle,  which  is  covered  by  the  three ; 
the  base,  or  the  anterior  part  of  this  space,  is  formed  from  above  down- 
ward by  the  femur,  by  the  popliteus  muscle,  which  covers  the  posterior 
ligament  of  the  articulation,  and  more  directly  by  an  adipose  body, 
which  separates  this  from  the  crucial  ligaments,  and  from  the  synovial 
membrane.     The  space  itself  is  contracted  and  less  elongated  below  ; 
k  contains  much  adipose  tissue,  three  or  four  lymphatic  ganglions 
which  surround  the  large  vessels,  and  a  fasciculus  of  nerves  and  ves- 
sels, formed  in  the  following  manner :  superficially,  by  the  bifurcated 
extremity  of  the  sciatic  nerve,  the  internal  popliteal  nerve,  continuing 
the  course  of  the  preceding,  and  placed  a  little  on  the  outside  of  the 
median  line  of  the  region :  then,  on  the  same  plane,  the  external  po- 
pliteal nerve,  directed  outward,  and  contiguous  to  the  external  wall, 
particularly  to  the  biceps  muscle ;  more  deeply,  the  popliteal  artery 
and  vein,  which  are  directly  contiguous,  the  first  behind  the  second, 
both  descending  from  the  internal  wall  toward  the  median  line,  which 
they  reach  in  the  space  between  the  condyles  of  the  femur.     Finally, 
we  remark,  that  the  internal  popliteal  nerve  does  not  rest  directly  on 
the  vessels,  and  that  sometimes  the  internal,  sometimes  the  external 
only,  more  frequently  both  of  them,  give  oif  at  this  part  their  filament, 
which  goes  to  form  the  external  saphena  nerve ;  that  the  popliteal 
artery  below  is  situated  on  the  outside  of  the  nerve,,  crossing  its  direc- 


KNEE.  331 

tion ;  afterwards  it  again  crosses  it,  and  in  an  opposite  direction,  and 
assumes  its  normal  position  in  the  leg. 

Development.  In  children,  the  knee  is  proportionally  very  large, 
and  projects,  particularly  on  the  inside ;  the  semi-cartilaginous  state 
of  the  lower  epyphisis  of  the  femur,  is  the  true  cause  of  this  arrange- 
ment, which  does  not  completely  disappear,  until  after  the  period  of 
puberty.  In  the  young  child,  when  growing,  this  region  is  for  a  long 
time  semi-flexed,  which  depends  on  the  debility  of  the  muscles,  but 
certainly  also  on  the  habit  of  retaining  this  position,  which  it  is  forced 
to  assume  in  utero ;  in  the  old  man,  muscular  debility  alone  causes 
the  same  result. 

Varieties.  In  the  female,  the  knee  is  always  more  prominent  on 
the  inside  than  in  the  male  ;  it  is  also  more  arched  outward ;  this 
double  arrangement  is  produced  by  the  great  breadth  of  the  pelvis, 
which  keeps  the  upper  extremities  of  the  thighs  separated  ;  hence,  it 
follows,  that  in  standing,  the  legs  in  the  female  not  being  separated 
farther  than  in  the  male,  in  her,  also,  the  thighs,  in  order  to  unite  with 
them  at  the  knee,  must  make  an  angle  which  is  more  prominent  in- 
ward, and  is  more  depressed  on  the  outside  in  proportion.  The  vessels 
and  nerves  in  this  part  are  often  divided  here  prematurely,  as  in  the 
elbow  ;  in  fact,  the  sciatic  nerve  is  not  unfrequently  separated  into 
two  branches  far  above  this  region  ;  the  division  of  the  popliteal  artery 
is  more  rare,  but  it  has  sometimes  been  seen,  as  by  Portal,  Sandifort, 
and  Ramsay.  In  some  individuals,  the  ligament  of  the  patella  is  un- 
usually long;  hence,  consequently,  the  situation  of  the  patella  is 
higher  than  usual,  and  the  knee  is  slightly  flexed,  even  during 
standing ;  authors  have  also  mentioned  a  peculiar  flattening  of  the 
pulley  of  the  femur,  even  from  the  influence  of  the  action  of  the 
muscles  alone,  which  disposes  to  dislocation. 

Uses.  The  knee  is  the  centre  of  the  motions  of  flexion  and  exten- 
sion of  the  leg  ;  the  latter,  also,  executes  in  it  some  lateral  motions,  as 
in  semi -flexion.  This  region  supports  the  weight  of  the  whole  body 
in  standing  on  the  knees,  in  which  attitude  the  skin,  being  pressed 
between  the  patella  and  the  ground,  is  painful.  The  sub-cutaneous 
mucous  bursa  prevents  the  skin  from  being  lacerated,  as  it  glides  from 
before  the  wounding  powers  ;  in  the  same  cases,  the  summit  of  the 
synovial  membrane  being  drawn  upward  by  the  small  sub-cruralis 
muscle,  cannot  be  jammed  between  the  patella  and  the  femur. 

Pathological  and  operative  deductions.  Wounds  of  the  knee  are 
not  very  serious,  unless  the  articulation  be  injured  ;  the  extent  of  the 
articular  surface  explains  the  violent  inflammation  which  may  then 
supervene.  The  synovial  membrane  is  situated  so  superficially  on 
the  sides  of  the  patella,  that  these  parts  are  easily  wounded.  Wounds 


382  TOPOGRAPHICAL  ANATOMY. 

at  the  anterior  part  and  sides  cannot  be  attended  with  severe  hemor- 
rhage;   this  is  not  the  case  with  posterior  wounds,  in  which  the 
popliteal  artery  and  its  attendant  vein  may  be  wounded  .together  or 
separately.     This  latter  result  is  necessarily  produced  only  by  an 
instrument  which  acts  forcibly  from  behind  forward,  in  the  middle  of 
the  ham;  this  is  confirmed  by  the  relation  of  the  two  vessels  which 
we  have  mentioned,  which  also  accounts  for  the  formation  of  varicose 
aneurisms  in  this  part.     The  division  of  the  sciatic  nerve  would  also 
be  a  very  severe  accident,  because   it  would  be  followed   with   a 
paralysis  of  the  whole  leg.     Fractures,  of  the  knee  are  situated  some- 
times in  the  patella,  sometimes  in  the  femur  or  the  tibia.     The  super- 
ficial position  of  the  patella  exposes  it  to  fracture ;  but  its  position 
frequently  has  no  effect  in  causing  a  fracture,  which  is  produced 
entirely  by  the  action  of  the  extensor  muscles  of  the  leg.     Most  of 
these  fractures  are  transverse;  this  explains  the  difficulty  experienced 
by  the  surgeon  in  preventing  the  ascent  of  the  superior  fragment, 
which  is  constantly  drawn  up  by  the  action  of  the  muscles,  while  the 
lower  fragment  remains  motionless ;  hence  the  union  generally  occurs 
by  means  of  a  fibrous  substance,  as  Pibrac  has  observed.     After  frac- 
tures of  the  patella,  united  by  an  intermediate  fibrous  substance,  the 
patient  feels  a  weakness  in  the  limb,  and  the  knee  is  a  little  more  flexed 
than  that  of  the  opposite  side.     Boyer  distinguishes  simple  fractures  of 
the  patella  from  tr^ose  cpmplicated  with  a  rupture  of  the  tendinous 
expansion  which  embraces  and  covers  it.     The  first  are  cured  much 
more  readily  than  the  others,  and  with  a  moderate  degree  of  separa- 
tion.    Longitudinal  fractures  of  the  patella  are  very  rare,  notwith- 
standing, the  longitudinal  direction  of  its  fibres,  which  direction  seems 
to  dispose  to  them ;  the  case  mentioned  by  La  Motte  proves  that  they 
are  not  very  serious.     Fractures  of  the  femur  which  take  place  directly 
above  the  condyles,  are  attended  with  a  peculiar  displacement;  the 
lower  fragment,  being  acted  upon  by  the  gastrocnemius  muscle,  is 
brought  backward  into  the  popliteal  space  ;   at  the  same  time,  the 
patella  is  brought  forward  by  the  vibratory  motion  of  the  condyles,  and 
the  knee  presents  a  singular  deformity:     Beclard,  in  his  courses,  men- 
tioned, that  he  had  seen  in  aged  females,  fractures  of  the  upper  part  of 
the  tibia  produced  by  the  contraction  of  the  flexor  muscles  of  the  leg, 
which  muscles  had  also  drawn  the  upper  fragment  into  the  ham ;  the 
internal  absorption  which  diminishes  the  thickness  of  the  parietes  of 
the  cavities  of  the  bones,  and  their  fragility,  caused  by  the  predominance 
of  the  calcareous  part  in  aged  people,  explains  these  fractures  satisfac- 
torily.    A  great  degree  of  external  violence  is  necessary  to  break  the 
ligaments  of  the  knee ;  its  dislocations  also,  which  cannot  occur  with- 
out this  rupture  in  a  greater  or  less  degree,  are  rare  and  very  serious. 


KNEE.  333 

Most  generally,  only  one  of  the  condyles  leaves  the  tibia,  while  the 
other  is  placed  in  the  cavity  of  the  first ;  the  luxation  is  then  imperfect ; 
it  is  always  easy  to  reduce  these  dislocations ;  the  rupture  'of  the  liga- 
ments explains  the  want  of  resistance  which  is  then  perceived.  The 
rarity  of  anterior  and  posterior  dislocations  does  not  depend,  as  has  been 
said,  on  the  resistance  of  the  crural  ligaments,  which  would  also  pre- 
vent a  lateral  dislocation,  but  upon  the  greater  or  less  number  of 
muscles,  which  powerfully  support  the  articulation  in  this  direction, 
while  the  lateral  parts  possess  this  advantage  only  in  a  slight  degree. 
The  prominence  of  the  internal  edge  of  the  patella  will  alone  account, 
as  Boyer  has  observed,  for  the  frequent  dislocations  of  this  bone  outr 
ward,  which  prominence  gives  a  purchase  to  the  powers  capable  of 
producing  this  displacement.  The  mal-formation  of  the  ligament  of 
the  patella  and  that  of  the  anterior  pulley  of  the  femur,  which  have 
been  mentioned,  so  dispose  to  this  change  of  relations,  that  even  the 
action  of  the  muscles  alone  may  then  produce  it ;  but  when  this  defect 
is  carried  very  far,  dislocation  becomes  a  permanent  state ;  then  the 
patella,  situated  at  first  on  the  side  of  one  of  the  condyles,  soon  glides 
posteriorly;  the  common  tendon  of  the  triceps  and  rectus  femoris 
muscles  is  brought  into  this  direction,  and  extends  beyond  the  centre  of 
the  motions  of  the  femoro-tibial  articulation  ;  hence  it  follows,  that  the 
muscles,  which  were  previously  extensors  of  the  leg,  haying  become 
flexors,  the  person  cannot  stand.  Beclard  has  proved,  by  his  dissec- 
tions, that  this  was  the  cause  of  the  constant  flexion  of  the  knee  in 
cul-de-jattes,  or  cripples  who  have  lost  the  use  of  their  legs  and  thighs, 
in  whom  also  the  dislocation  of  the  patella  is  generally  congenital. 
Synovial  tumors  or  ganglions  sometimes  appear  in  the  knee ;  some- 
times they  are  situated  in  the  sub-cutaneous  mucous  bursa,  sometimes 
in  that  which  lubricates  the  posterior  face  of  the  ligament  of  the 
patella ;  we  have  once  found  in  the  latter  part,  these  loose  lenticular 
foreign  bodies  mentioned  when  speaking  of  the  gluteal  region,  together 
with  an  abundance  of  synovia.  Pus  may  also  accumulate  in  the 
former,  after  a  contusion,  to  which  it  is  exposed  also  by  its  superficial 
position ;  in  one  case  which  we  had  occasion  to  observe,  the  abscess 
was  left  to  itself  and  opened  into  the  articulation.  Abscesses  of  the 
ham  rarely  terminate  in  this  manner,  on  account  of  the  resistance  of 
the  articulation  in  this  direction.  Collections  of  pus  in  this  part  also 
are  extremely  serious  for  another  reason  ;  they  are  diffuse  on  account 
of  the  laxity  of  the  cellular  tissue,  and  if  left  to  themselves,  they  destroy 
the  muscles,  the  vesselsj  -and  the  nerves,  burrow  toward  the  thigh  in 
the  posterior  sheath,  or  toward  the  leg  along  the  tibial  vessels,  and  in 
the  space  between  the  gastrocnemius  and  soleus  muscles;  some 
abscesses  of  the  ham  are  formed  by  pus  from  the  thigh  or  from  a  higher 


334  TOPOGRAPHICAL    ANATOMY. 

place.  Spontaneous  aneurisms  are  frequently  situated  in  the  popliteal 
artery ;  this  phenomenon  has  been  explained  by  pathologists  in  diffe- 
rent ways  ;  in  fact,  some  say,  that  it  is  caused  by  the  compression  of 
the  artery,  when  it  passes  under  the  contracted  soleus  muscle,  which 
compression  causes  the  stagnation  of  the  blood  above ;  others  have 
ascribed  this  disease  to  the  traction  of  the  vessels  during  the  forced  ex- 
tension of  the  leg.  Anatomy  will  demonstrate  to  us  that  the  first 
opinion  is  inadmissible  ;  this  would  be  the  case  with  the  second  also, 
if  the  artery  were  always  healthy  and  extensible ;  in  fact,  we  have 
seen  that  it  forms  some  slight  sinuosities,  that  it  presents  internally 
some  transverse  folds,  which  belong  to  its  internal  membrane,  which 
folds,  in  fact,  are  in  reserve  to  admit  of  the  extension  of  the  knee ;  but 
when  the  artery  is  diseased,  particularly  when  it  is  ossified,  the  expla- 
nation of  the  formation  of  aneurism  by  rupture,  seems  much  more 
probable,  as  the  vessel  has  lost  its  extensibility,  and  has  become 
extremely  fragile.  When  the  aneurismatic  artery  is  obliterated, 
whether  spontaneously  or  by  an  operation,  the  collateral  circulation  of 
the  knee  becomes  more  important,  as  it  carries  blood  into  the  lower 
part  of  the  limb ;  we  can  then  conceive  the  use  of  the  recurrent  tibial 
artery,  which  carries  the  blood  directly  from  the  articular  arteries  into 
the  anterior  tibial  artery.*  The  articular  arteries  are  obliterated  at 
their  origin,  since  they  arise  from  the  popliteal  artery,  which  we  have 
supposed  to  be  changed  into  an  impermeable  cord  ;  their  dilated 
branches,  however,  receive  blood  from  the  deep  femoral  artery,  or  from 
its  perforating  branches,  and  continue  the  circulation.  As  the  superior 
articular  arteries  often  rise  very  high,  when  the  femoral  artery  has 
been  tied  for  popliteal  aneurism,  we  can  conceive  that  the  arterial 
trunk  may  not  be  obliterated  from  the  ligature  to  the  tumor ;  this 
arrangement  has  never  prevented  a  cure.  Farther,  this  fact  also  is 
connected  with  the  action  of  ligatures  on  arteries ;  these  are  generally 
obliterated  above  and  below  the  point  tied,  but  only  to  the  origin  of  a 
great  collateral  artery. 

Besides  the  physical  injuries  of  the  articulation  which  have  been 
mentioned,  it  may  also  be  affected  spontaneously  in  different  ways  ; 
foreign  cartilaginous  bodies  sometimes  form  in  it ;  we  have  seen  two 
cases  of  this  kind,t  and  Beclard  has  often  stated  they  arise  in  the 
synovial  fringes,  on  the  outside  of  the  cavity  of  the  synovial  membrane, 
that  they  soon  project  into  the  articulation,  and  become  loose  by  the 
rupture  of  the  pedicle  which  supports  them ;  hence  they  present  in 

*  We  have  recently  dissected  a  subject  in  whom  the  popliteal  artery  was  obliterated  on 
one  side,  and  in  whom,  during  life,  the  anterior  tibial  artery  received  no  blood,  except  through, 
this  unusual  channel. 

|  We  have  known  one  of  these  bodies  to  be  developed  in  the  adipose  ligament. 


KNEE.  335 

their  formation  three  distinct  periods,  according  to  the  place  where 
they  are  formed.  The  great  number  of  the  synovial  fringes  of  this 
articulation  explains  the  frequency  of  the  development  of  these  foreign 
bodies,  which  cause  severe  pains  when  they  are  interposed  between 
the  cartilaginous  surfaces,  and  the  existence  of  which  is  not  per- 
ceived in  other  cases.  The  constant  irritation  of  the  synovial  mem- 
brane of  the  knee  by  walking,  accounts  for  the  appearance  of 
hydarthrosis  in  this  region  ;  this  synovial  tumor  ascends  first  upward 
under  the  triceps,  in  the  very  loose  tissue  which  unites  this  muscle  to 
the  femur  ;  the  patella  is  then  pushed  forward  and  the  fibrous  expan- 
sion of  its  edges  yields  ;  hence  the  appearance  of  two  lateral  promi- 
nences, the  internal  of  which  is  the  larger  because  on  this  side  the 
articulation  is  weak  in  a  greater  extent.  These  two  prominences  are 
more  tense  and  more  prominent  during  the  contraction  of  the  triceps, 
because  then  they  are  as  it  were  strangulated  in  the  centre  by  the 
patella  and  its  ligament ;  farther,  the  simple  sub-patellar  ganglion 
which  we  have  mentioned,  has  sometimes  been  termed  hydarthrosis  ;  it 
differs  from  the  latter,  however,  by  its  lower  position.  The  knee  is 
very  subject  to  those  more  or  less  extensive  articular  diseases,  vaguely 
termed  white  swellings.  In  this  part,  particularly,  this  term  has  been 
applied,  not  only  to  certain  diseases  of  the  bones,  cartilages,  synovial 
membranes  and  ligaments,  but  also  to  the  morbid  tumefaction  of  the 
sub-patellar  adipose  body,  to  the  diseases  of  the  mucous  bursa  situated 
before  it,  and  to  a  simple  disease  of  the  fatty  mass  which  exists  poste- 
riorly, between  the  crucial  ligaments  and  the  posterior  ligament; 
finally,  in  one  very  remarkable  case,  we  have  found  that  the  tubercu- 
lous and  scrofulous  swelling  of  the  popliteal  ganglions  was  the  only 
disease  of  a  knee  apparently  affected  with  a  white  swelling.  The 
knee  is  often  affected  with  pains  in  the  direction  of  its  posterior 
nerve;  they  constitute  sciatic  neuralgia;  sometimes,  particularly  in 
coxalgia,  the  knee  is  affected  with  severe  sympathetic  pains,  which 
have  deceived  physicians,  and  have  led  them  to  suspect  a  disease  of 
the  region  ;  the  sciatic  nerve  may  perhaps  be  regarded  as  the  conductor 
of  them ;  from  its  position  near  the  articulation  of  the  haunch,  which 
is  affected,  we  may  suppose  in  these  cases  that  it  is  more  or  less 
irritated.  If  we  wish,  in  the  region  of  the  knee,  to  tie  the  popliteal 
artery  which  passes  through  it  posteriorly,  where,  for  instance,  it  has 
been  extensively  wounded,  a  perpendicular  incision  must  be  made  on 
the  centre  of  the  harn ;  we  divide  successively,  the  skin,  the  sub-cuta- 
neous cellular  tissue,  some  ramifications  of  the  posterior  cutaneous 
nerve  of  the  thigh  and  of  the  external  saphena  vein,  the  fascia  lata 
aponeurosis ;  we  leave  on  the  outside,  the  internal  and  external 
popliteal  nerves ;  the  vein  should  be  separated  from  the  artery,  and 


336  TOPOGRAPHICAL    ANATOMY. 

also  left  on  the  outside ;  and  before  it,  we  find  the  artery  surrounded 
by  several  lymphatic  ganglions.  Although  amputation  near  the  knee 
has  been  performed  successfully  by  several  surgeons,  and  has  been 
advised  by  Brasdor,  yet  it  is  generally  considered  as  less  convenient 
than  that  of  the  thigh ;  the  extent  of  the  articular  surfaces  which  in 
this  case  are  exposed  to  the  irritating  action  of  the  air,  are  reasons  for 
this  opinion  ;  if  we  decide  to  perform  it,  we  must  make  but  one  poste- 
rior flap,  in  which  the  principal  vessels  and  nerves  are  situated  ;  it  is 
usually  advised  to  terminate  by  this  flap,  and  this  accords  with  the 
general  rules  of  the  operations  ;  but  the  operation  is  performed  more 
rapidly  and  more  regularly,  if  we  follow  an  opposite  course,  and 
introduce  the  knife  posteriorly,  and  cut  first  the  single  flap.  This 
small  deviation  from  the  rule  is  attended  with  no  inconvenience,  but  it 
possesses  all  the  advantages  we  have  mentioned.  . 


CHAPTER      III, 


THfRD       PART       OFflifi       ABDOMltfAL       LIMB. 

The  third  section  of  the  abdominal  lirnb  commences  below  the)' 
knee,  and  unites  inferiorly  with  the  foot.  It  is  composed  of  the  leg 
and  the  ankle. 


1.       OF      THE      LEG. 

The  leg  commences  below  the  knee,  and  is  separated  from  the 
ankle  by  an  imaginary  line  drawn  two  fingers'  breadth  above  the 
summit  of  the  internal  malleolus  ;  it  is  irregularly  fusiform,  is  en- 
larged in  the  centre,  and  unequally  thin  near  its  extremities  ;  its 
direction  is  perpendicular  to  the  horizon,  and  is  parallel  to  that  of  the 
opposite  leg,  in  which  it  differs  from  the  thigh.  Considered  on  the 
outside,  we  distinguish  in  it  three  faces,  more  or  less  covered  with 
hairs,  particularly  the  internal :  this  latter  is  plane,  and  a  little  arched 
on  the  outside  ;  the  skeleton  is  very  superficial  there,  and  can  be  felt 
in  every  part ;  the  external  face  is  anterior,  and  uniformly  convex ; 
the  posterior  presents,  at  the  union  of  the  upper  third  with  the  two 
lower  thirds,  the  muscular  prominence  of  the  calf;  in  a  strong  and; 


LEO.  357 

well  made  man,  the  circumference  of  the  calf  is  nearly  double  that  of 
the  base  of  the  leg,  estimated  above  the  malleoli ;  nevertheless,  there 
are,  in  this  respect,  numerous  individual  varieties  ;  the  anterior  edge 
of  the  leg  is  very  prominent,  like  a  crest ;  it  marks  one  of  the  edges  of 
the  tibia ;  along  the  inner  edge,  which  is  a  little  blunt,  we  see  the 
bluish  prominence  of  the  great  saphena  vein  ;  finally,  on  the  superior 
limits  of  this  region,  we  see  three  eminences,  all  formed  by  prominences 
of  bone  j  they  are,  on  the  inside,  the  corresponding  tuberosity  of  the 
tibia,  on  the  outside,  the  head  of  the  fibula,  anteriorly,  the  anterior 
tuberosity  of  the  tibia,  which  serves  as  a  point  of  attachment  to  the 
ligament  of  the  patella.  These  different  remarks  will  form  the  base 
of  useful  applications. 

Structure.  —  1.  Elements:  The  leg  is  one  of  the  simplest  of  the 
four  sections  of  the  abdominal  limb,  in  respect  to  structure  ;  its  skeleton 
is  formed  of  two  bones,  the  central  part  of  which  alone  belongs  to  it, 
excepting,  however,  the  fibula,  the  upper  extremity  of  which  also 
exists  there  ;  of  these  two  parts,  the  tibia  belongs  particularly  to  the 
leg  by  its  functions,  while  the  fibula  is  destined  more  particularly  to 
the  mechanism  of  the  ankle  and  the  foot,  as  we  shall  see  ;  these  two 
bones  are  separated  by  an  inter-osseous  space,  which  is  imperfectly 
filled  with  the  inter-osseous  membrane  ;  they  are  also  united  directly 
by  compact  articulations,  which  do  not  admit  of  rotatory  motions  as 
in  the  fore-arm.  The  muscles  of  the  leg  are  situated  on  its  anterior, 
external,  and  posterior  faces  ;  the  tibialis  anticus,  the  extensor  hallucis 
proprius,  the  extensor  digitorum  pedis  communis,  and  the  peroneus 
anticus,  on  the  first ;  on  the  second,  the  peronei  laterales ;  and  finally, 
the  gastrocnemius,  the  soleus,  the  plantaris,  the  flexor  digitorum  pedis 
communis,  the  tibialis  posticus,  and  the  flexor  hallucis  proprius,  on 
the  last.  Some  come  from  the  region  of  the  knee,  and  others  arise  in 
the  leg  and  go  toward  the  ankle  and  the  foot.  If  we  except  the  soleus, 
their  arrangement  is  not  essential,  and  will  not  detain  us ;  but  we 
must  make  a  few  remarks  on  this  muscle,  because,  although  described 
minutely  in  many  excellent  works,  its  importance  has  not  been  recog- 
nised ;  we  will  merely  mention,  that  it  is  attached  to  the  tibia,  the 
fibula,  and  between  them,  to  a  tendinous  arch,  under  which  the  pos- 
terior tibial  vessels  and  nerves  pass  :  an  aponeurosis  extends  from  this 
attachment  to  the  oblique  line  of  the  tibia,  on  its  anterior  face,  to  which 
we  shall  allude  hereafter,  when  treating  of  the  ligature  of  the  posterior 
tibial  artery.  We  find,  also,  at  the  upper  and  internal  part  of  the  leg, 
the  aponeurotic  expansion  of  the  sartorius,  gracilis,  and  semi-mem- 
branosus  muscles.  The  aponeurosis  of  the  leg  is  strengthened  at  the 
upper  part,  as  we-  have  seen,  by  expansions,  which  are  sent  to  it  by 
most  of  the  muscles  of  the  knee  ;  below,  it  is  also  strengthened,  and 

43 


338  TOPOGRAPHICAL  ANATOMY. 

comes  on  the  ankle  ;  its  internal  face  adheres  to  the  sub-cutaneous 
face  and  edges  of  the  tibia,  and  sends  some  fibrous  septa  towards  the 
anterior  and  external  edges  of  the  fibula,  between  the  tibialis  anticus 
and  the  extensor  digitorum  communis  longus,  and  at  the  same  time  it 
gives  many  points  of  insertion  to  the  anterior  an<J  external  muscles  ; 
finally,  it  sends  also  between  the.  deep  and  superficial  muscles,  a  layer 
which  is  very  strong  below,  and  more  and  more  thin  as  it  ascends. 
Thus,  the  aponeurosis  of  the  leg  forms  four  principal  muscular  sheaths  ; 
one  anterior,  one  external,  a  third  which  is  superficial  and  posterior, 
a  fourth  which  is  deep  and  posterior.     We  cannot  regard  these  anterior 
muscles  as  each  provided  with  a  special  sheath ;   the  septa  which 
separate  them  exist  above  only,  and  are  even  very  imperfect ;  a  very 
small  supernumerary  sheath  usually  belongs  to  the  external  saphena 
vein.     The  arteries  of  the  leg  are  given  off  by  three  principal  trunks, 
which  pass  through  it  and  go  downward  ;  the  anterior  and  posterior 
tibial,  and  the  peroneal  arteries  j  the  latter,  also,  bifurcates  inferiorly, 
and  sends  forward  one  of  its  divisions.     We  remark,  that  the  anterior 
tibial  artery,  which  passes  above  through  the  inter-osseous  ligament, 
to  go  forward,  and  the  tibio-peroneal  trunk  which  remains  posteriorly, 
are  the  two  terminating  branches  of  the  popliteal  artery,  which  is 
thus  situated  on  the  upper  part  of  the  inter-osseous  ligament;  the 
different  secondary  ramifications  of  the  arteries  generally  anastomose 
with  each  other  ;  but  the  anterior  system  particularly  communicates 
with  the  posterior,  by  means. of  small  branches  which  pass  through 
the  inter-osseous   ligament,  and  are  termed  perforating  arteries  ;  of 
these,  the  anterior  peroneal  artery  is  the  largest.     Some  small  anasto- 
rnotic  arteries  also  exist  on  the  outside,  and  unite  the  same  systems ; 
we  have  once  found  these  latter  very  much  developed  in  a  cadaver, 
where  the  upper  part  of  the  anterior  tibial  artery  was  morbidly  oblite- 
rated.    When  speaking  of  the  knee,  we  have  seen  how  the  anterior 
arterial  system  of  the  leg  communicates  with  that  of  this  region,  by 
the  recurrent  tibial  artery.     The  small  deep  veins  of  the  leg  accompany 
the  arteries  ;  they  are  very  valvular,  and  are  arranged  in  pairs  ;  the 
superficial  form  a  considerable  plexus  inward  and  backward,  and  go 
into  the  trunk  of  the  internal  and  external  saphena  veins,  which  only 
pass  through  this  region,  continually. -increasing  there  however.     The 
lymphatic   system  of  the   leg   is  composed  of  a  ganglion,  situated 
below,  on  the  course  of  the  anterior  tlbi'al  vessels,  of  numerous  super- 
ficial vessels  on  the  inside,  which  go  t&fh'e  superficial  ganglions  of  the 
groin,  and  of  deep  vessels,  which  are  much  more  rare,  and  which 
proceed  to  the  popliteal  ganglions/     The  nerves  of  the  leg  are  given 
off  particularly  by  the  external  and  internal  popliteal  ;  they  are  the 
anterior  tibial,  the  musculo-cutaneous,  the  posterior  tibial,  and  the 


LEG.  339 

external  saphena  branches;  the  internal  saphena  nerve,  which  also 
goes  there,  emanates  from  the  crural  nerve.  The  cellular  tissue  of 
the  leg  presents  nothing  peculiar  ;  it  forms  a  mucous  bursa  below  the 
aponeurotic  expansion  termed  the  pes  anseris  ;  it  contains  some  adi- 
pose vesicles  under  the  skin  only ;  this  presents  nothing  particular, 
except  the  quantity  of  hair  which  exists  upon  it. 

2.  Relations.  The  skin,  the  sub-cutaneous  cellulo-fatty  tissue,  and 
the  superficial  layer  of  the  aponeurosis,  are  the  three  layers  common 
to  the  circumference  of  the  leg.  As  in  all  the  other  points  of  the 
limbs,  the  sub-cutaneous  layer  is  more  compact,  is  thinner,  and  less 
fatty  forward,  on  the  outside,  and  particularly  on  the  inside,  than  pos- 
teriorly ;  it  contains,  on  the  inside,  the  internal  saphena  vein,  the 
internal  saphena  nerve,  and  the  largest  fasciculus  of  the  superficial 
lymphatic  vessels  ;  outward  and  upward,  it  contains  some  small  ter- 
minating filaments  of  the  inguino-cutaneous  nerve ;  outward  and 
downward,  the  musculo-cutaneous  nerve,  which  leaves  its  deep  position, 
then  divides  into  two  branches,  which  incline  forward  ;  backward  and 
upward,  some  filaments  of  the  posterior  cutaneous  nerve  of  the  thigh  ; 
finally,  backward  and  downward,  we  find  there  the  saphena  nerve  and 
vein,  which  leave  their  special  sheath. 

Under  the  aponeurosis,  anteriorly,  we  find  the  anterior  sheath,  in 
which  the  tibialis  anticus  and  the  extensor  digitorum  communis 
muscles  unite  by  a  septum,  and  form  a  first  layer,  which  is  attached 
forward  to  the  aponeurosis,  and  rests  posteriorly  on  the  bones  and  on 
the  inter-osseous  ligament ;  while  still  lower,  the  two  muscles  which 
form  it  are  no  longer  united,  and  cover  by  their  approximation,  first, 
the  upper  end  of  the  extensor  hallucis  proprius,  which  afterwards 
separates  them,  and  is  situated  at  their  level ;  finally,  on  the  outside  of 
this  layer,  we  see  the  peroneus  tertius  muscle,  which  is  often  blended 
with  the  common  extensor  of  the  toes. 

This  anterior  muscular  layer,  thus  formed  by  two  muscles  above, 
and  by  four  below,  presents  in  the  first  point  a  single  interstice,  and 
two  others  below  ;  the  first,  which  is  unique  above,  arid  internal  in  its 
inferior  prolongation,  may  be  termed  the  anterior  tibial ;  it  is  formed 
on  the  inside  by  the  tibialis  anticus  muscle  alone,  on  the  outside,  by 
the  extensor  communis  above,  and  the  extensor  hallucis  proprius 
below  ;  and  finally,  behind,  by  the  inter-osseous  ligament :  it  contains 
the  anterior  tibial  and  peroneal  vessels,  which  penetrate  into  it  directly 
from  behind  forward,  and  the  anterior  tibial  nerve,  the  course  of  which 
is  oblique  from  without  inward.  This  latter  is  situated  successively 
on  the  outside,  in  front,  and  on  the  inside  of  the  vessels.  The  second 
and  third  interstices  are  of  little  importance ;  one  is  formed  by  the 


340  TOPOGRAPHICAL    ANATOMY. 

proper  and  common  extensor,  the  other  by  this  latter  and  the  peroneus 
tertius  muscle. 

On  the  inside  of  the  leg,  the  tibia  is  found  in  every  part,  directly 
under  the  aponeurosis,  except  at  the  upper  part,  where  it  is  separated 
from  it  by  the  pes  anseris  aponeurosis,  and  by  a  very  humid  mucous 
bursa,  which  is  deeper  than  this  last  part. 

On  the  outside,  is  a  very  strong  sheath,  common  to  the  two  peronei 
laterales  muscles,  one  of  which  is  superficial,  and  very  long,  and  ex- 
tends the  whole  length  of  the  leg,  while  the  other  is  deep,  and  extends 
only  to  its  three  lower  fourths.  At  the  upper  part,  the  external 
popliteal  nerve  descends  obliquely  forward,  and  always  in  the  sheath 
of  which  we  are  speaking,  between  the  peroneus  posticus  muscle  and 
the  neck  of  the  fibula ;  its  anterior  tibial  branch  passes  directly  into 
the  anterior  tibial  interstice,  while  the  musculo-cutaneous  branch  is 
situated  first  between  the  peronei  muscles,  along  the  septum,  which 
separates  the  anterior  and  external  sheaths,  soon  leaves  this  deep  posi- 
tion, and  becomes  sub-cutaneous  at  the  union  of  the  upper  two  thirds 
with  the  lower  third  of  the  leg. 

Posteriorly,  under  the  aponeurosis,  we  penetrate  into  the  first  sheath, 
which  contains  all  the  muscles  of  the  calf,  the  gastrocnemius  superfi- 
cially, the  plantaris  in  the  centre,  the  soleus  deeply,  all  of  which  are 
united  below  in  a  very  simple  tendon,  the  Achilles  tendon  :  the  poste- 
rior wall  of  this  sheath  contains  above  the  external  saphena  vein, 
which  is  contiguous  to  the  end  of  the  posterior  cutaneous  nerve  of  the 
thigh ;  the  external  saphena  nerve,  and  its  double  root  are  first  sub- 
aponeurotic,  but  at  the  same  part,  below,  the  external  saphena  reins 
and  nerves  become  sub-cutaneous,  and  are  contiguous  to  each  other.* 
Under  all  the  above  parts,  which  properly  form  the  calf,  we  come  on 
the  deep  layer  of  the  aponeurosis,  which  separates  the  two  posterior 
sheaths  ;  this  layer  rests  directly  on  the  flexor  digitorum  communis 
on  the  inside,  the  flexor  hallucis  proprius  on  the  outside,  in  the  centre, 
on  the  tibialis  posticus  and  the  posterior  tibial  vessels  and  nerves, 
which  incline  inward  toward  the  corresponding  malleolus,  the  nerve 
constantly  remaining  on  the  outside  of  the  vessels.  The  peroneal 
vessels  are  first  situated  on  the  same  plane  as  the  tibial,  and  like  them, 
consequently,  are  covered  directly  by  the  aponeurosis  mentioned ;  but 
they  soon  pass  deeply  between  the  flexor  hallucis  proprius  and  the 
tibialis  posticus,  the  latter  of  which  covers  them  entirely  below,  when 
they  have  cpme  upon  the  inter-osseous  ligament. 

Development.  The  leg  is  the  second  section  of  the  pelvic  limb 
which  appears  after  this  is  formed.  It  is  always  flexed  in  the  fetuSj 

*  The  external  saphena  nerve  and  vein  are  more  properly  termed  posterior. 


LEG.  341 

and  presents   also  a  very  marked  curve,  which  never  completely 
disappears. 

Varieties.  The  size  and  length  of  the  leg  vary  much  in  individuals. 
The  calf,  a  characteristic  of  our  species,  and  a  strong  argument  against 
the  opinion  of  sophists,  who  assert  that  we  were  not  born  for  the  erect 
posture — the  calf  is  more  or  less  developed,  and  is  situated  more  or 
less  superiorly ;  its  circumference,  compared  to  that  of  the  base  of  this 
region,  also  varies  more  or  less  from  the  normal  state. 

In  the  female,  the  calf  is  larger,  but  above  the  malleoli  the  leg  is  a 
little  smaller,  proportionally,  than  in  the  male.  The  plantaris  and 
peroneus  tertius  muscles  are  often  deficient.  Sometimes  the  soleus 
muscle  is  inserted  very  low  on  the  inner  edge  of  the  tibia.  We  not 
unfrequently  find  at  the  base  of  the  leg,  posteriorly,  and  in  the  deep 
sheath,  a  small  accessory  flexor  muscle,  analogous  to  the  common 
superficial  flexor  muscle  of  the  fore-arm  ;  this  supernumerary  muscle 
generally  blends  in  the  foot  with  the  accessory  muscle  of  the  common 
flexor.  In  a  young  girl,  whom  we  recently  dissected,  we  found  in  the 
leg  a  very  small  muscle,  situated  on  the  inside  of  the  tibialis  anticus 
muscle,  terminated  by  a  tendon  on  the  tibia,  above  the  internal  mal- 
leolus,  and  arising  very  distinctly  in  the  middle  of  the  leg.  This 
variety  seems  to  us  to  represent,  in  this  part,  the  supinator  longus 
muscle  of  the  fore-arm.  We  have  also  found  a  small  fleshy  fasciculus, 
which  went  to  the  flexor  digitorum  brevis  muscle. 

The  anterior  tibial  artery  may  also  be  very  small  above,  and  may  be 
very  much  enlarged  below  by  the  anterior  peroneal  artery ;  this  is 
simply  a  development  of  the  normal  arrangement ;  sometimes  it  termi- 
nates in  the  centre  of  the  leg,  and  is  replaced  below  by  the  very  large 
anterior  peroneal  artery ;  in  these  cases,  the  peroneal  trunk  is  very 
much  enlarged.  We  often  find,  between  the  ends  of  the  peroneal  and 
of  the  posterior  tibial  artery,  a  very  large  anastomotic  branch,  which 
descends  obliquely  from  the  peroneal  artery  ;  this  is  simply  an  increase 
of  the  normal  arrangement;  in  some  rare  cases,  it  is  carried  to  a 
greater  extent,  and  then  changes  the  end  of  the  posterior  tibial  artery 
into  a  branch  of  the  peroneal  artery.  We  have  recently  dissected  a 
subject  in  whom  the  peroneal  artery  Was  enormously  developed,  and 
might  be  considered  as  the  continuation  of  the  popliteal  artery ;  it 
divided  below  into  three  branches ;  one  of  them  passed  through  the 
inter-osseous  ligament,  and  went  to  form,  the  lower  part  of  the  anterior 
tibial  artery  ;  another  represented  the  normal  posterior  peroneal  artery; 
finally,  the  last  passed  under  the  tarsus,  and  had  the  common  ar- 
rangement of  the  posterior  tibial  artery ;  the  two  anterior  and  pos- 
terior tibial  arteries  were  rudimentary,  and  were  distributed  in  the 
centre  of  the  leg,  constantly  anastomosing  with  the  branches  which 


342  TOPOGRAPHICAL    ANATOMY. 

continued  them  downward.  The  external  saphena  nerve  often  pre- 
sents some  varieties  in  the  arrangements  of  its  two  roots  ;  sometimes 
that  of  the  external  popliteal,  and  sometimes  that  of  the  internal  is  the 
larger  ;  sometimes  both  come  from  these  trunks  in  the  popliteal  space  ; 
sometimes  one  of  them  separates  in  the  middle  of  the  leg,  from  one  of 
the  branches  of  the  popliteal  nerves.  Sometimes  one  of  these  roots  of 
the  external  saphena  nerve  is  situated  in  the  gastrocnemius  muscle. 

Uses.  The  leg  supports  the  weight  of  the  body  which  is  trans- 
mitted to  it  obliquely  by  the  femur.  Hence  the  advantage  derived 
from  its  perpendicular  direction,  from  the  strength  of  its  skeleton,  and 
its  numerous  posterior  muscles.  It  has  been  incorrectly  asserted  that 
the  contraction  of  the  soleus  muscle  might  compress,  in  this  part,  the 
end  of  the  popliteal  artery  ;  but,  on  the  contrary,  the  fibres  of  this 
muscle,  by  drawing  upon  the  aponeurotic  arch,  under  which  this 
vessel  passes,  dilate  the  opening  for  its  transmission. 

Pathological  and  operative  deductions.  We  have  frequently  seen 
partial  or  complete  ruptures  of  some  fibres  of  the  muscles  of  the  calf; 
these  are  explained  by  the  violent  efforts  required  by  leaping,  walk- 
ing, &c. 

The  most  simple  injuries  of  the  leg,  on  the  inside  and  along  the 
crest  of  the  tibia  cause  severe  pains,  while  they  are  hardly  felt  in  any 
other  part.  Anatomy  shows,  that  in  these  other  parts  the  skin  is  re- 
moved from  the  bones,  the  only  resisting  point  of  support,  by  elastic 
masses  of  muscles,  which  resist  all  shocks  ;  there,  on  the  contrary,  the 
relations  of  the  skin  with  the  bones  is  almost  direct.  In  the  first  points, 
the  blood  is  effused  as  easily  as  in  the  occipito-frontal  region,  and  from 
the  same  causes.  Wounds  of  the  leg,  if  a  little  deep,  are  often  com- 
plicated with  the  injury  of  its  principal  vessels  ;  hence,  these  vessels 
frequently  require  to  be  tied.  To  come  to  the  anterior  tibial  artery, 
we  must  cut  in  the  direction  of  a  line  drawn  from  the  head  of  the 
fibula  to  the  centre  of  the  ankle,  which  direction  is,  as  we  have  stated, 
that  of  the  interstice  of  this  vessel :  we  must  carefully  avoid  its  attend- 
ant nerve,  which  occupies  the  position  we  have  mentioned ;  farther, 
we  must  flex  the  foot,  in  order  to  relax  the  anterior  jnuscles  of  the  leg 
as  much  as  possible,  which  state  of  relaxation  allows  us  to  raise  the 
artery  more  easily,  especially  if  we  are  careful  to  do  this  with  a  curved 
instrument  introduced  diagonally  into  the  interstice.  It  is  very  easy 
to  find  the  posterior  tibial  artery  below,  between  the  Achilles  tendon 
and  the  internal  edge  of  the  tibia ;  we  must  not,  however,  forget  that 
it  is  situated  in  the  deep  posterior  sheath,  and  consequently,  that  it  is 
separated  from  the  skin  by  two  distinct  aponeuroses  ;  it  should  be  raised 
from  without  inward,  to  avoid  the  nerve  which  accompanies  it  on  the 
outside.  At  the  ripper  part  of  the  leg,  this  same  artery  is  covered  by 


LEG.  34S 

the  mass  of  the  muscles  of  the  calf,  and  seems  almost  inaccessible, 
especially  if  we  reflect  that  the  soleus  muscle  which  covers  it,  being 
inserted  in  the  inner  edge  of  the  tibia,  must  be  divided,  and  thus  it  is 
difficult  to  discover  the  moment  when  the  cutting  instrument  has  come 
into  the  interstice  of  the  vessels  :  on  account  of  these  difficulties,  and 
particularly  the  last,  a  compression  of  the  vessels  has  been  preferred  to 
a  ligature ;  this  compression,  however,  is  difficult  and  inefficient.  We 
have  attempted  to  find,  in  the  anatomical  arrangement  of  the  parts, 
some  sure  guide  by  which  these  obstacles  may  be  overcome  ;  we  have 
discovered  it  in  the  structure  of  the  soleus  muscle.  This  muscle,  at 
its  upper  part,  two  lines  from  the  internal  edge  of  the  tibia,  on  its  ante- 
rior face,  which  is  situated  directly  on  this  vessel,  presents  an  aponeu- 
rosis,  to  which  the  incision  should  always  extend ;  in  fact,  as  long  as 
we  do  not  find  it,  we  are  certain  that  we  are  still  in  the  muscle  ;  on 
dividing  it,  we  open  the  interstice  of  the  vessels.  This  direction  being 
laid  down,  it  will  be  easy  to  tie  the  posterior  tibial  artery  high  up, 
if  we  make  an  incision  parallel  to  the  inner  edge  of  the  tibia  and 
at  least  two  lines  behind  it,  which  will  interest  the  skin,  the  sub-cuta- 
neous tissue,  leaving  on  the  inside  the  internal  saphena  vein  and  its 
attendant  nerve,  but  dividing  the  tibial  aponeurosis,  the  soleus  muscle 
and  its  aponeurosis.  The  tibial  artery  is  then  exposed,  and  is  covered 
only  by  a  very  thin  fibrous  layer  of  the  crural  aponeurosis,  and  should 
be  raised  with  care,  in  order  to  avoid  the  tibial  nerve,  which  is  situated 
near  it,  on  the  outside.  It  is  more  difficult  to  find  the  peroneal  artery 
than  the  posterior  tibial  ;  in  order  to  come  to  this  at  the  upper  part, 
we  must  divide  the  soleus  muscle,  near  its  attachment  to  the  fibula, 
but  in  a  place  where,  unfortunately,  there  is  no  aponeurosis  which 
might  serve  as  an  infallible  guide  on  the  inside.  This  same  artery  may 
be  found  lower  down  where  it  rests  against  the  inter-osseous  ligament, 
by  making  an  incision  on  the  outer  edge  of  the  Achilles  tendon,  which 
incision  must 'include  the  superficial  and  deep  layers  of  the  crural 
aponeurosis  ;  the  flexor  hallucis  longus,  and  the  tibialis  posticus,  must 
then  be  separated,  for  the  artery  is  situated  between  them ;  but,  if  the 
first  incision  has  been  made  near  the  posterior  edge  of  the  fibula,  we 
may  also  detach  from  the  posterior  face  of  this  bone  the  flexor  hallucis 
proprius  muscle,  and  we  shall  thus  arrive  more  certainly  to  the  inter- 
osseous  ligament,  on  which  the  artery  rests.  When  we  cannot  find 
the  injured  artery  at  the  upper  part  of  the  leg,  we  may  tie  the  end  of 
the  femoral  artery  or  the  popliteal  artery ;  Dupuytren  has  done  this 
successfully,  in  a  case  where  the  posterior  tibial  artery  had  been 
wounded  very  high  up  by  a  spicula  of  bone.  In  performing  this  ope- 
ration, however,  we  must  always  guard  against  hemorrhage,  an  almost 
necessary  result  of  the  re-establishment  of  the  circulation,  as  is  proved 


344  TOPOGRAPHICAL  ANATOMY. 

by  the  practice  of  Guthrie  and  Bell.     Aneurisms  of  the'  upper  part  of 
the  leg  require  only  the  ligature  of  the  femoral  artery ;  the  re-establish- 
ment of  the  circulation,  which  is  so  easy  by  the  anastomoses  of  the 
articular  arteries  with  the  recurrent  tibial  artery,  does  not  then  impede 
the  cure,  as  the  velocity  of  the  course  of  the  blood  in  the  leg  is  mode- 
rated on  account  of  the  greater  dilatation  of  the  collateral  arteries,  and 
thus  the  tumor  has  time  to  disappear.     A  similar  treatment  would 
doubtless  succeed  in  aneurisms  of  the  lowest  parts  of  the  artery ;  but 
it  is  better  to  tie  the  diseased  vessel  above  and  below  the  tumor,  to 
prevent  the  blood  from  coming  there  by  a  retrograde  course,  by  fol- 
lowing anastomoses  which  are  naturally  very  much  dilated,  and  which 
are  presented  below  by  all  the  arteries  of  the  leg.     In  fractures  of  this 
region,  the  fragments  suffer  but  little  displacement,  except  that  pro- 
duced by  the  cause  of  the  fracture  ;  this  depends  upon  two  reasons, 
first,  because  the  same  muscles  are  inserted  on  both  fragments  ;  the 
second,  because,  if  only  one  of  the  two  bones  is  fractured,  that  which 
is  uninjured  serves,  in  a  measure,  as  a  splint  for  the  other.     Never- 
theless, in  perfect  fractures,  the  extremities  of  the  fragments  often  form 
anteriorly  an  angular  prominence,  which  is  produced  by  the   con- 
traction of  the  posterior  muscles  which  draw  the  opposite  extremities' 
of  the  fragments  towards  each  other.     In  fractures  of  the  fibula,  the 
fragments  are  drawn  towards  the  tibia  by  the  action  of  the  muscles 
which  are  inserted  in  both  bones,  principally  by  the  tibialis  posticus 
muscle.     There  is  no  anatomical  arrangement  which  will  explain  the 
constant  direction  downward  and  outward  of  the  oblique  fracture  of 
the  tibia.     When  one  of  the  bones  of  this  region  is  broken,  it  is  impos- 
sible to  stand  ;  the  reason  of  this,  however,  varies,  according  to  the 
bone  affected  :  if  the  tibia  be  broken,  the  leg  having  lost  its  axis,  refuses 
to  support  the  weight  of  the  body,  while  when  the  fibula  is  broken, 
the  foot  ceases  to  perform  its  office.     The  superficial  position  of  the 
tibia  inside,  its  size,  and  also  its  constant  and  difficult  functions,  expose 
it  more  than  any  other  part  to  necrosis.     When  we  wish  to  remove  the 
sequestra,  which  is  often  inclosed  in  a  new  bone,  the  internal  face  of  this 
region  should  be  selected  for  the  incisions,  on  account  of  the  thinness 
of  the  integuments.     This  same  superficial  position  of  the  bone,  which 
serves  as  the  base  of  the  leg,  explains  the  appearance  of  syphilis  in  it, 
which  frequently  causes  in  it  exostoses  and  periostoses :  these  tumors 
occur  there  so  frequently,  that  the  physician  should  always  examine 
this  part,  in  a  patient  suspected  of  a  chronic  and  constitutional  syphilitic 
affection.     Varices  of  the  leg  are  very  common  ;  they  occur  most  fre- 
quently on  the  inside,  by  the  dilatation  of  the  great  saphena  vein  and 
of  its  branches ;  they  are  less  common  posteriorly,  in  the  small  saphena 
vein,  doubtless  because  its  crural  portion  does  not  ascend  so  high,  and 


ANKLE.  345 

supports  a  shorter  column  of  blood  than  the  corresponding  portion  of 
the  internal  saphena  vein.  Abscesses  are  seldom  formed  in  the  front 
part  of  the  leg :  posteriorly,  on  the  contrary,  they  are  common  in  the 
calf:  the  pus  which  forms  them  may  easily  burrow  between  the  gas- 
trocnemius  and  the  soleus  muscles,  especially  before  the  latter  :  it  may 
come  from  the  ham,  or  even  from  a  higher  point>  after  passing  through 
the  former.  The  rules  for  amputating  the  leg  are  all  founded  on  ana- 
tomical precepts  ;  let  us  examine  them  successively  ;  first,  the  operator 
is  situated  on  the  inside,  in  order  to  divide  evenly  the  two  bones  situ- 
ated on  a  plane  oblique  downward  and  outward,  when  the  leg  is  held 
horizontally;  For  the  division,  we  select  a  point  situated  four  fingers' 
breadth  below  the  anterior  tuberosity  of  the^tibia,  because,  at  this  part, 
the  popliteal  artery  is  divided,  the  nutritious  artery  of  the  tibia  has  not 
yet  entered  its  canal  of  transmission,  the  tendons  which  form  the 
pes  anseris,  and  with  them  the  motions  of  flexion  of  the  stump,  are 
preserved,  and  finally,  because  the  length  of  the  stump  is  best  adapted 
for  fitting  an  artificial  leg.  The  muscles  should  be  cut  at  one  period 
as  far  as  the  bone,  because  they  do  not  form  two  layers  except  poste- 
riorly, and  even  in  this  part,  near  their  superior  insertions,  they  are 
nearly  equally  retractile.  They  are  united  obliquely  from  before  back- 
ward, and.  from  within  outward,  to  cause  the  anterior  angle  of  the 
tibia  to  correspond  to  one  of  the  angles  of  the  wound,  as  the  bone  might 
otherwise  compress  one  of  the  flaps  and  injure  it,  and  also^  because  the 
diameter  of  the  leg  is  largest  in  this  direction.  Beclard  has  proposed, 
in  order  to  prevent  gangrene,  in  consequence  of  the  pressure  of  the 
angle  of  the  tibia  against  the  anterior  flap,  to  remove  this  angle  ob- 
liquely. After  amputating  the  leg,  we  have  always  to  tie  the  two 
tibial,  the  peroneal,-  and  the  muscular  arteries,  especially  those  of  the 
gastrocnemius  and  soleus  muscles.  Where  hemorrhage  supervenes 
after  this  operation,  instead  of  irritating  the  stump  by  looking  for  the 
bleeding  vessels,  we  should  imitate  the  bold  course  of  Roux  and  Du- 
puytren,  and  tie  the  femoral  artery.  Ribes  very  justly  attributes  the 
powerful  retraction  of  the  arteries  of  this  region,  after  amputation,  to 
the  position  of  the  end  of  the  popliteal  artery  on  the  upper  part  of  the 
inter-osseous  ligament,  a  fixed  point  to  which  the  first  contract* 


2.      OP      THE      ANKLE. 

The  ankle  is  the  angle  of  union  of  the  leg  and  foot ;  it  is  a  region 
which  comprises  the  group  of  organs  situated  around  the  tibio-tarsal 
articulation,  and  which  extends  two  fingers'  breadth  above  and  below* 
the  malleolus. 

44 


346  TOPOGRAPHICAL  ANATOMY. 

The  ankle  is  much  more  rounded  than  the  wrist;  its  transverse 
diameter,  at  the  level  of  the  malleoli,  is  as  long  as  the  antero-posterior 
diameter. 

On  its  external  surface  are  four  very  marked  eminences  ;  a  posterior, 
which  belongs  to  the  Achilles  tendon  ;  an  anterior,  which  marks 
externally  the  fasciculus  of  the  flexor  tendons  of  the  foot,  and  is  more 
prominent  during  the  contraction  of  their  muscles ;  two  lateral,  termed 
the  malleoli,  which  are  prominences  of  bone.  Of  the  two  latter,  the 
internal  is  larger  from  before  backward^  but  less  prominent  and  shorterf 
and  is  situated  more  anteriorly  than  the  external.  The  preceding 
eminences  are  separated  by  four  depressions  ;  they  are  situated  before 
and  behind  each  malleolus,  and  serve  to  detach  them  still  more  ;  the 
two  posterior  are  separated  by  the  Achilles  tendon,  and  are  more 
distinct  than  the  anterior  ;  the  external  more  so  than  the  internal. 

Structure. —  1.  Elements.  The  elements  of  this  region  are  the 
tibio-tarsal  articulation,  some  tendons,  an  aponeurosis,  the  extended 
vessels  of  the  leg  or  foot,  some  nerves,  and  a  little  of  cellular  and 
adipose  tissue.  The  tibio-tarsal  articulation  forms  the  base  which 
supports  the  rest ;  the  bony  parts  of  this  articulation  are  the  pulley  of 
the  astragalus  on  one  side,  on  the  other  a  cavity,  elongated  transversely, 
to  which  the  two  bones  of  the  leg  contribute,  a  kind  of  mortice  bounded 
by  the  two  malleoli.  We  must  also  remember  carefully,  first,  that 
the  fibula  contributes  to  form  its  outside,  and  touches  only  the  outer 
part  of  the  astragalus ;  second,  that  the  prolongation  of  this  boner 
which  forms  the  external  malleolus,  descends  four  lines  below  the 
opposite  prolongation  of  the  tibia ;  third,  that  the  articular  bands  are 
three  strong  ligaments  on  the  outside,  one  only  on  the  inside,  and  two 
others  which  are  rudimentary,  one  anterior,  the  other  posterior ;  fourth, 
that  the  axis  of  the  articulation  falls  nearer  the  internal  than  the  ex- 
ternal edge  of  the  foot ;  fifth,  finally,  that  the  transverse  diameter  of 
the  mortice  of  the  leg  is  very  nearly  equal  to  that  of  the  pulley  of  the 
astragalus.  The  astragalus  and  its  double  articulation  with  the 
scaphoides  and  os  calcis,  also  belong  to  the  ankle,  and  likewise  the 
inferior  tibio-peroneal  articulation,  which  is  remarkable  for  the  strength 
of  its  anterior,  posterior,  and  middle  ligaments.  We  shall  see,  here- 
after, the  importance  and  application  of  these  facts.  The  ankle  has 
no  special  muscle  ;  but  few  fleshy  fibres  are  visible  there,  and  the 
muscles  of  the  leg  send  there  merely  their  tendons.  Anteriorly,  we 
find  the  tendons  of  the  tibialis  anticus,  of  the  extensor  communis  and 
proprius,  and  of  the  peroneus  anticus ;  on  the  outside,  those  of  the 
peronei  laterales  ;  posteriorly,  the  Achilles  tendon,  and  the  tendons  of 
the  flexor  digitorum  communis,  the  flexor  proprius,  and  the  tibialis 
posticus  ;  the  flexor  digitorum  communis  brevis  also  arises  there  below 


ANKLE.  347 

and  forward.  The  aponetirosis  of  the  ankle  is  continuous  upward 
and  downward  with  those  of  the  leg  and  foot,  of  which  it  makes  a 
part ;  but  its  strength  in  this  part  is  singularly  increased  ;  its  superfi- 
cial face  presents,  near  its  internal  malleolus,  an  opening,  through 
which  an  anastomotic  vein  passes  ;  it  is  intimately  attached  on  the 
outer  faces  of  the  malleoli,  and  unites  with  their  periosteum ;  it  is 
composed  of  transverse  or  more  or  less  oblique  fibres ;  it  is  formed 
posteriorly  of  two  very  distinct  layers,  which  are  those  from  the  pos- 
terior face  of  the  leg ;  this  formation  by  two  layers  exists  anteriorly 
only  at  the  annular  ligament ;  in  some  points,  it  presents  very  distinct 
fasciculi,  which  keep  in  place  the  tendons  ;  one  anterior,  the  dorsal 
annular  ligament,  is  oblique  from  the  tibia  toward  the  anterior  de- 
"pwfSsion  of  the  external  malleolus;  it 'is  formed  of  two  layers,  the 
separation  of  which,  in  three  points,  contributes  to  form  three  grooves 
for  the  anterior  muscles,  of  which  grooves,  that  of  the  tibialis  anticus 
is  very  thin  anteriorly;  another  fasciculus  of  the  same  aponeurosis 
constitutes  the  external  annular  ligament ;  it  is  extended  between  the 
fibula  and  the  astragalus,  and  forms,  with  the  bone,  a  groove,  simple 
superiorly,  divided  inferiorly,  into  two,  by  a  septum.  Finally,  a  third 
fasciculus,  the  internal  annular  ligament,  is  inserted  on  the  internal 
malleolus  and  the  corresponding  part  of  the  os  calcis,  and  forms  a 
kind  of  bridge,  under  which  pass  all  the  deep  posterior  tendons,  con- 
tained in  special  ossjeo-fibrous  grooves,  among  which  there  is  one  for 
the  flexor  proprius  longus,  another  single  above  and  cleft  below,  for 
the  tendons  of  the  common  flexor  and  of  the  tibialis  posticus,  which  are 
first  united,  but  afterward  separate.  The  common  groove  is  formed 
by  the  superficial  layer  of  the  aponeurosis ;  the  deep  layer,  attached 
on  the  internal  malleolus  and  the  astragalus,  forms  special  grooves. 
Three  considerable  arteries,  the  two  tibial  and  the  peroneal,  come 
from  the  leg-  into  this  region  ;  all  send  to  it  some  branches  ;  one  only 
terminates  here,  the  peroneal.  The  secondary  arteries  are  the  malleo- 
lar,  and  the  anterior  arid  posterior  peroneal.  Besides  the  anastomoses 
which  exist  between  all  these  branches,  in  the  plexus  which  they  form 
around  the  malleoli,  and  in  which  the  dorsal  artery  of  the  tarsus  enters, 
there  are  also  others,  which  cause  a  more  extensive  communication 
between  the  anterior  and  posterior  trunks,  or  simply  between  the  for- 
mer ;  thus,  a  constant  branch  establishes  a  communication  between 
the  anterior  peroneal  and  the  anterior  tibial  artery,  either  directly  or 
by  means  of  the  external  malleolar  artery.  Tlje  posterior  peroneal 
artery  anastomoses  also  with  the  posterior  tibial*  artery,  more  or  less 

*  This  arrangement  of  the  posterior  tibial  and  peroneal  arteries  is  analogous  to  that  of  the 
radial  and  ulnar  arteries,  before  the  wrist,  under  the  pronator  quadratus.     It  is  the  posterior 


348  TOPOGRAPHICAL   ANATOMY. 

directly,  as  has  already  been  mentioned  when  speaking  of  the  leg. 
Two  veins  generally  follow  the  course  of  each  of  these  arteries,  and 
are  deep  like  them  ;  others  form  a  sub-cutaneous  layer  ;  these  are  the 
two  saphenae  and  some  of  their  twigs.  This  superficial  venous  layer 
communicates  with  the  deep  layer  of  the  ankle  by  different  anastomotic 
branches,  the  largest  of  which  unites  directly  the  internal  saphena  and 
one  of  the  anterior  tibial  veins,  passing  through  a  foramen  of  the  apo- 
neurosis,  which  has  been  mentioned  to  exist  in  front  of  the  internal 
malleolus.  A  lymphatic  ganglion,  termed  the  supra-tarsal,  is  often 
situated  at  the  upper  and  anterior  part  of  the  ankle,  in  the  course  of 
the  anterior  tibial  vessels  ;  the  deep  and  interior  lymphatic  vessels  go 
to  it ;  the  others  ascend  to  the  popliteal  ganglions.  Some  of  the  superr 
fieial  lymphatic  vessels  go  also  into  the  latter  ganglions,  following  the 
external  saphena  vein  ;  but  most  of  them  accompany  the  internal  to 
the  ganglions  of  the  groin,  through  which  they  pass.  The  anterior, 
posterior,  musculo-cutaneous,  and  saphena  nerves,  pass  through  th'is 
region,  and  give  to  it  some  twigs  ;  the  first  two  are  deep-seated,  the 
others  are  superficial  and  cutaneous.  The  cellular  tissue  is  more 
abundant  posteriorly,  around  the  Achilles  tendon,  than  anteriorly  and 
on  the  sides ;  in  the  first  point,  it  contains  many  adipose  vesicles ; 
anteriorly,  but  few  of  these  vesicles  exist,  while  none  are  seen  at  the 
malleoli,  where  the  cellular  tissue  becomes  exceedingly  loose,  and 
sometimes  forms  a  mucous  bursa ;  the  tendinous  sheaths,  mentioned 
jabove,  are  lubricated  by  simple  or  complex  mucous  membranes ;  ano- 
ther membrane,  which  is  also  very  constant,  is  extended  between  the 
Achilles  tendon  and  the  os  calcis.  The  skin  is  fine  on  the  inside  and 
.anteriorly,  an,d  more  dense  posteriorly  and  on  the  outside. 

2.  Relations.  The  skin,  the  sub-cutaneous  celluloTfatty  tissue,  and 
the  aponeurosis,  form  three  layers,  common  to  the  whole  of  this  region  ; 
even  the  aponeurosis  exists  at  the  malleoli,  for  in  these  points  it  is 
attached  to  the  periosteum,  The  sub-cutaneous  layer  contains,  first, 
in  front  of  the  internal  malleolus,  the  internal  saphena  nerve  and  vein  ; 
second,  more  anteriorly,  the  branches  of  the  musculorcutaneous  nerve. 
•On  the  malleoli,  where  this  layer  is  very  thin,  it  contains  some  fila- 
ments of  the  corresponding  saphenas  nerves,  and  behind  the  external 
malleolus,  the  external  saphena  nerve  and  vein. 

Below  the  aponeurosis,  and  anteriorly,  we  find,  beside  the  flexor 
digitorum  brevis,  from  the  tibia  toward  the  fibula,  the  tibialis  anticus, 
-the  extensor  hallucis  proprius,  the  extensor  digitorum  communis, 
and  the  peroneus  anticus  united,  each  enclose^  in  a  sheath,  which  has 


part  of  a  vascular  circle,  formed  anteriorly  and  on  the  sides  by  the  malleolar  arteries :  this 
ring  is  analogous  to  the  vascular  bracelet  of  the  wrist. 


ANKLE.  349 

been  described,  and  which  is  lubricated  by  a  very  moist  synovial 
membrane ;  the  anastomotic  branch  of  the  great  saphena  and  of  the 
anterior  tibial  veins,  passes  near  the  internal  malleolus,  below  the 'ten- 
don of  the  tibialis  anticus  muscle  ;  these  veins,  with  the  anterior  tibial 
.artery  and  nerve,  are  situated  below  the  sheath  of  the  extensor  hallucis 
proprius,  and  cross  its  direction,  while  the  anterior  peroneal  artery  is 
concealed  by  that  of  the  common  extensor.  All  these  parts  rest  on  the 
bones  of  the  leg,  the  anterior  ligament  of  the  tibio-tarsal  articulation, 
and  the  upper  part  of  the  neck  of  the  astragalus. 

Posteriorly,  the  aponeurosis  being  removed,  we  see  a  superficial 
sheath  for  the  Achilles  tendon,  a  tendon  lubricated  downward  and 
forward  by  a  mucous  bursa,  and  enveloped  anteriorly  and  on  the  sides 
by  a  considerable  adipose  body,  in  which  ramify,  simultaneously,  the 
posterior  peroneal  artery  and  some  filaments  of  the  external  saphena 
nerve ;  next  comes  the  deep  layer  of  the  aponeurosis,  resting,  first,  on 
the  flexor  hallucis  proprius  on  the  outside,  the  flexor  digitorum  com- 
munis  in  the  centre,  and  the  tibialis  anticus  on  the  inside ;  second,  on 
the  posterior  tibial  vessels  and  nerves,  which  are  situated  in  a  special 
sheath,  between  those  of  the  flexor  digitorum  communis  and  the  flexor 
hallucis  proprius  ;  third,  on  the  posterior  peroneal  vessels. 

These  parts  cover  deeply  the  posterior  face  of  the  tibia,  of  the  fibula, 
of  the  inferior  tibio-peroneal  articulation,  the  posterior  ligament  of  the 
tibio-tarsal  articulation,  and  the  posterior  face  of  the  astragalus. 

Laterally,  the  aponeurosis  blends  with  the  periosteum  of  the  mal- 
leoli,  and  leaves«io  space  between  it  and  these  eminences  ;  but  lower 
than  these  latter,  and  posteriorly,  we  find  the  anastomosis  of  the 
malleolar  and  plantar  vessels,  the  tendons  which  are  situatecj^bn  each 
side,  in  a  groove,  which  is  at  first  simple,  but  afterwards  divided,  and 
covers  the  lateral  ligaments  of  the  tibio-tarsal  articulation,  and  also 
the  corresponding  faces  of  the  astragalus,  These  tendons,  on  the 
inside,  are  those  of  the  tibialis  posticus,  which  proceed  parallel  to  the 
inner  edge  of  the  foot,  and  of  the  flexor  digitorum  longus,  which 
penetrates  under  the  plantar  arch  ;  on  the  outside,  those  of  the  peronei 
laterales,  the  peroneus  brevis  being  directed  parallel  to  the  inner  edge 
of  the  foot,  and  the  peroneus  longus  soon  penetrating  below  the  cuboid 
bone. 

Development.  In  the  child,  the  tibio-tarsal  region  is  very  weak ; 
the  prolonged  and  epiphysary  external  malleolus  fulfils  its  functions 
only  in  part ;  hence,  standing  and  walking  are  at  first  impossible,  and 
are  for  a  long  time  unsteady. 

Varieties.  The  vessels  and  muscles  of  this  part  vary  much  ;  most 
of  these  varieties  were  mentioned  in  speaking  of  the  leg ;  it  is  in  this 
point,  for  instance,  that  the  abnormal  arrangements  of  the  tibial  and 


350  TOPOGRAPHICAL  ANATOMY. 

peroneal  arteries  often  commence  here.  We  have  seen  the  external 
malleolar  artery  give  off  the  dorsal  artery  of  the  foot ;  this  latter  is 
then  not  situated  in  the  position  mentioned,  but  it  is  carried  very  much 
outward,  under  the  flexor  digitorum  communis  brevis  muscle. 

Uses.-  The  ankle  supports  the  weight  of  the  whole  body,  and 
transmits  it  directly  to  the  last  section  of  the  limb.  Its  mechanism  in 
this  transmission  is  very  important  and  very  curious  ;  first,  its  position 
above  the  place  where  the  inner  edge  of  the  foot  rests  partially  on  the 
ground,  and  secondly,  the  length  of  the  external  malleolus  place  the 
foot  between  two  equal  and  opposite  powers,  which  reciprocally  destroy 
each  other  in  the  normal  state ;  one  would  constantly  tend  to  rotate  it 
outward,  were  it  not  for  the  resistance  of  the  other,  which  acts  in  an 
opposite  direction.  Destroy  this  equilibrium,  or  suppose  it  to  be 
destroyed  by  disease,  and  the  deviation  of  the  foot,  in  consequence  of 
its  rotation,  becomes  inevitable.  In  walking,  this  region  becomes  the 
point  of  the  lever  of  the  foot,  where  the  resistance  to  motion  is  situated  ; 
we  can  then  imagine  the  importance  of  the  perpendicular  insertion  of 
the  Achilles  tendon,  arid  that  of  the  posterior  prominence  of  the  os 
calcis.  The  ankle  admits  of  motions  of  flexion,  extension,  adduction, 
abduction,  and  circumduction ;  the  first  take  place  exclusively  in  the 
tibio-tarsal  articulation ;  the  second  belong  only  to  the  astragalo- 
calcanosan  and  scaphoid  articulations.  Hence,  some  anatomists  are 
incorrect  in  saying,  that  the  tibio-tarsal  articulation  admits  of  lateral 
motions  which  impede  the  mechanism  of  the  ankle,  and  that  of  the 
foot.  In  the  lateral  motions,  or  in  those  of  adduction  and  abduction, 
the  foot  is  balanced  in  this  region  by  two  orders  of  opposite  muscles, 
the  tibialis  anticus  and  posticus  on  one  side,  the  peronei  on  the  other  : 
these  muscles  must  establish  an  equilibrium,  in  order  for  the  mechanism 
of  the  ankle  to  be  regular.  We  shall  mention,  hereafter,  the  application 
of  these  facts  in  a  pathological  point  of  view. 

Pathological  and  operative  deductions.  The  lesions  of  this  region 
are  very  common  ;  this  depends  naturally  on  its  violent  uses,  during 
efforts  in  walking,  jumping,  &c.  Cases  of  rupture  of  the  Achilles  ten- 
don have  been  mentioned ;  its  extreme  force,  however,  must  render 
this  injury  very  rare ;  we  can  imagine  in  the  child,  that  it  may  be 
detached  from  the  foot  with  the  posterior  part  of  the  os  calcis,  which  is 
formed  by  an  epiphysis  which  does  not  fuse  until  late.  The  Achilles 
tendon  is  more  easily  divided  in  wounds  ;  farther,  in  all  these  cases,  it 
is  important  to  keep  the  two  ends  of  the  tendon  in  contact,  in  order  to 
have  a  narrow  cicatrix,  which  circumstance  may  alone  be  considered 
as  a  perfect  cure,  since  in  this  case  only  the  motions  preserve  their 
strength.  Different  dressings  have  been  invented  for  this  purpose  by 
surgeons.  Wounds  of  this  region  may  be  attended  with  wounds  of 


ANKLE.  35* 

the  tibial  and  peroneal  arteries  ;  in  applying  a  ligature  to  these  vessels, 
there  is  nothing  peculiar,  except  what  has  been  mentioned  when 
speaking  of  the  leg.     In  falling,  or  merely  in  walking,  if  the  foot  does 
not  rest  flat  upon  the  ground,  it  rotates  in  the  -region  of  which  we  are 
speaking ;  if  this  rotation  is  not  carried  far,  it  produces  no  bad  symp- 
toms ;  but  if,  on  the  contrary,  it  is  very  extensile,  a  sharp  pain  and 
other  more  or  less  serious  symptoms  are  felt.     Tfe  abnormal  rotation> 
the  cause  of  this  disease,  may  take  place  inward  o?  outward  ;  hence  a 
distinction  of  sprains  into  external  and  internal.    In  order  to  under- 
stand the  mechanism  of  a  sprain,  we  must  reme.nber  the  compact 
nature  of  the  tibio-tarsal,  the  astragalo-calcanrean,  and  scaphoid  arti- 
culations, and  their  mechanism.     When  the  foot  is  carried  in  the 
direction  of  abduction  or  adduction,  the  latter  articulations  are  normally 
the  centre  of  motion  ;  but  if  this  motion  is  rendered  tmnatural  by  vio^ 
lence,  the  tibio-tarsal  articulation  also  becomes  with  thsm  the  centre  of 
the  abnormal  motions.     In  the  simplest  sprain,  the  ligaments  are  only 
bruised  ;  but.  in  a  more  complex  case,  they  are  fractured  ;  luxations 
and  fractures  also  may  sometimes  be  produced.     Several  causes  con- 
tribute to  render  an  external  sprain  very  rare,  and  also  explain  the 
frequency  of  internal  sprains;  these  causes  are,  the  number  of  the  lateral 
ligaments,  the  length  of  the  external  malleolus,  and  the  constant  ten- 
dency of  the  foot  to  abduction  in  standing,  which  tendency  we  have 
explained  by  the  internal  position  of  the  ankle,  above  the  concavity  of 
the  inner  edge  of  the  last  section  of  the  limb.     A  sprain  is  always 
serious,  because  the  rupture,  or  at  least  the  Bruising  of  tne  articular 
bands  of  the  ankle,  opposes  its  action,  prevents  walking  and  standing, 
and  also  exposes  to  a  great  number  of  more  or  less  serious  injuries  of  the 
articulations  of  this  region.     The  malleoli,  being  pressed  from  within 
outward  by  the  astragalus,  may  be  broken  in  severe  strains.     The  tibia 
cannot  be  fractured  beyond  the  internal  malleolus  simply  by  the  forced 
rotation  of  the  foot ;  this  is  not  true  of  the  fibula,  on  account  of  its 
greater  weakness  and  the   flexibility   which  results  from  the   first 
arrangement.     The  following  is  the  manner  in  which  the  fracture  is 
produced  ;  it  rarely  occurs  in  an  external  sprain,  but  it  is  sometimes 
seen  ;  then  the  astragalus  presses  the  fibular  malleolus  from  \vithin 
outward,  the  peroneo-tarsal  lateral  ligaments  yield,  the  fibula  vibrates 
in  its  lower  peroneo-tibial  articulation,  by  which  the  summit  of  the 
malleolus  is  carried  outward,  while  it  curves  above  the  ankle,  and 
soon  breaks.     The  fibula  is  more  frequently  fractured,  as  we  have  re- 
marked, in  internal  sprains,  which  are  also  more  common  for  the 
reasons  already  mentioned ;  the  mode  in  which  it  is  produced  is  then 
Very  different.     The  astragalus,  which  tends  to  go  inward,  causes 
the  distension   and  sometimes  the  rupture  of  the  internal   lateral 


352  TOPOGRAPHICAL   ANATOMY. 

ligament,  while  the  external  ligaments  are  uninjured  ;  the  malleolus? 
of  the  fibula  then  revolres  on  its  point  against  the  external  face  of  the' 
os  calcis,  which  pushes  it  upward ;  but  the  solidity  of  the  peroneo-tibial 
articulations  prevent  ihis  ascension,  and  the  bone,  being  curved  only 
in  one  point,  is  soon  broken.     In  every  fracture  of  the  fibula,  the  inferior 
fragment  being  drawn  toward  the  tibia,  as  has  been  said  when  speak- 
ing of  the  leg,  executes  a  vibratory  motion,  by  which  the  external 
malleolus  is  removed  on  the  outside  from  the  internal ;  the  transverse 
diameter  of  the  crural  mortice  is  increased,  and  is  no  longer  in  relation 
with  that  of  the  astragalus  ;•  the  external  malleolus  does  not  support 
this  bone,  and  the  equilibrium  is  destroyed  between  the  two  powers, 
which,  in  the  normal  state,  oppose  the  rotation  of  the  foot ;  hence 
lateral  motions  occur,  which  then  take  place  only  in  the  tibio-tarsal 
articulation,  whenever  the  foot  rests  on  the  ground,  which  motions 
prevent  standing.     In  order  to  cure  a  fracture  of  the  fibula,  we  must 
bring  the  external  malleolus  to  its  usual  distance  from  the  internal, 
Counterbalancirg  the  action  of  the  displacing  powers,  and  causing  the 
external  malleoius  to  vibrate  from  without  inward ;  in  order  to  do  this, 
many  surgeons  merely  apply  the  common  apparatus  for  fractures  of 
the  leg,   pushmg  up  the  internal  splint  and  bringing  the  external 
splint  very  lov,  so  as  to  compress  the  external  malleolus.    Dupuytren 
e'mploys  an  apparatus,  the  action  of  which  is  founded  on  the  very 
great  resistance  of  the  ligaments  of  the  tibio-tarsal  articulation  on  the 
outside,  and  on  the  soundness  of  the  peroneo-tarsal  ligaments  in  most 
fractures  of  the  fibula.     He  draws  the  summit  of  the  malleolus  by 
means  of  the  external   lateral   ligaments   from  without  inward,  by 
carrying  and  fixing  the  foot  in  the  direction  of  adduction.     This  very 
ingenious  mode  cannot  apply  to  all  cases,  and  particularly  to  fractures 
produced,  as  we  have  seen,  in  external  sprains,  and  complicated  with 
the  rupture,  or,  at  least,  with  the  distension  of  the  external  lateral 
ligaments.     The  first  apparatus,  which  is  constantly  and  successfully 
used  by  Roux  and  Boyer,  admits,  on  the  contrary,  of  universal  appli- 
cation.    In  violent  distensions  of  the   ankle,   we   not  unfrequently 
observe  the  rupture  of  the  bands  which  unite  the  astragalus  to  the 
os  calcis,  the  rotation  of  the  first  of  these  bones  on  its  axis,  and  its 
double  dislocation  on  the  leg  and  the  os  calcis ;  this  is  a  very  serious 
injury,  and  often  requires  the  extirpation  of  the  dislocated  astragalus ; 
but  it  may  sometimes  be  cured  by  the  reduction  of  the  displaced  parts. 
Common  dislocations  of  the  foot,  in  the  tibio-tarsal  articulation,  are 
always  serious  on  account  of  the  rupture  of  the  ligaments,  which  cir- 
cumstance renders  the  reduction  very  easy.     Hydarthrosis  of  the  ankle 
is  very  common ;  it  is  marked  externally  by  two  tumors,  situated  before 
the  malleoli,  where,  in  fact,  the  articulation  is  the  most  superficial. 


ANKLE.  355 

and  the  weakest.  White  swellings  of  the  ankle  present  nothing  pecu- 
liar. We  not  unfrequently  find  synovial  tumors  on  the  malleoli,  in 
those  individuals  who  wear  narrow  and  high  shoes  ;  in  fact,  the  loose 
cellular  tissue  of  these  parts  often  rises  and  forms  a  mucous  bursa  from 
the  effect  of  a  long  continued  pressure :  sometimes  this  is  situated  in 
the  small  mucous  bursae,  which  have  been  mentioned  as  existing 
around  the  tendons.  We  not  unfrequently  find  a  real  ganglion  formed 
by  the  accumulation  of  synovia  in  the  mucous  bursa  of  the  Achilles 
tendon.  Roux  has  proposed,  for  the  resection  of  the  bones  of  the  leg 
in  this  region,  a  method  which  is  combined  ingeniously  with  the 
structure  of  the  parts ;  it  consists  in  cutting  upon  the  bones  inside  and 
outside,  and  in  extending  the  necessary  incisions  forward,  but  only  to 
the  fasciculus  of  the  flexor  tendons,  which  must  be  carefully  preserved. 
The  extirpation  of  the  foot,  although  mentioned  by  Hippocrates  as  not 
very  serious,  should  not  be  performed,  because  it  leaves  exposed  a  very 
broad  osseous  surface,  which  can  hardly  be  covered  with  the  flaps 
formed  only  by  the  skin  and  some  tendons,  and  also,  because  the  lower 
part  of  the  leg  would  be  inconvenient  for  the  application  of  an  artifi- 
cial foot.  The  region  of  the  ankle  is  sometimes  the  centre  of  the 
deformity  known  as  club-foot,  in  which,  as  Scarpa  has  observed,  there 
is  not  dislocation  of  the  bones,  but  only  a  rotation  of  them  around  their 
smaller  axis  ;  generally,  however,  as  Scarpa  observes,  the  astragalus 
does  not  participate  in  this  rotation.  In  one  subject,  however,  which 
we  dissected  at  the  Hospital  des  Enfans,  and  in  which  there  was  a  club- 
foot  on  each  side,  and  the  external  deformity  was  well  marked,  we  found 
that  on  one  side  the  astragalus  retained  its  normal  position  ;  on  the 
other,  it  was  rotated,  so  that  its  inner  face  looked  to  the  tibia.  Farther, 
throwing  out  of  view  causes  which  are  not  anatomical,  the  debility  of 
the  internal  or  external  lateral  muscles  of  the  ankle  constitutes  a  com- 
mon cause  of  .this  disease,  by  the  want  of  equilibrium,  which  results 
from  this  fact. 

45 


354  TOPOGRAPHICAL  ANATOMY. 


CHAPTER      IV. 


FOURTH  SECTION   OF   THE   ABDOMINAL   LIMB, 

OF    THE    FOOT. 

The  foot  is  the  last  part,  or  the  loose  section  of  the  pelvic  limb. 

Man  is  both  bimanous  and  biped ;  two  circumstances  which  cha- 
racterize him  in  the  series  of  animals. 

The  foot  is  situated  in  a  horizontal  plane,  being  distinguished  by  this 
from  all  the  other  limbs.     It  is,  at  least,  one  third  longer  than  the 
hand;  its  breadth  increases  progressively  from  behind  for  ward;,  its 
height,  on  the  contrary,  presents  an  opposite  arrangement ;  the  latter 
is  greater  on  the  inside  than  on  the  outside.     The  foot  presents  two 
faces,  two  edges,  and  two  extremities.     The  upper  dorsal  face  is  united 
posteriorly  with  the  ankle ;  anteriorly,  it  is  loose,  convex,  and  directed 
a  little  obliquely  outward  :  the  superficial  veins  and  the  tendons  appear 
on  it.     The  inferior  or  plantar  face  is  smooth,  concave  in  the  centre, 
and  on  the  inner  edge,  parts  which  generally  do  not  rest  on  the  ground, 
and  which  are  therefore  covered  with  a  very  fine  skin  :  in  standing, 
this  face  projects  posteriorly,  anteriorly,  and  on  the  outside  rests  on  the 
ground,  and  is  therefore  callous  in  some  parts.     The  inner  edge  of  the 
foot,  is  concave  inward,  and  particularly  downward  ;  when  placed  on 
a  plane,  it  rests  upon  it  only  anteriorly,  near  the  great  toe.     At  the 
union  of  the  posterior  with  the  two  anterior  thirds  of  this  edge,  we  see 
a  very  marked  tuberosity,  which  belongs  to  the  scaphoides,  and  directly 
behind  Avhich  the  astragalo-scaphoid  articulation  is  situated  :  lo  the 
centre,  corresponds  the  inner  part  of  the  tarso-metatarsal  articulation, 
which  is  indicated  anteriorly  by  the  slight  prominence  of  the  posterior 
extremity  of  the  first  metatarsal  bone.     The  external  edge  is  shorter 
and  flatter  than  the  preceding  :  it  also  rests  almost  entirely  on  a  hori- 
zontal plane  :  it  is  convex  on  the  outside,  and  is  elevated  in  the  centre 
by  a  tuberosity,  which  belongs  to  the  fifth  metatarsal  bone,  a  tuberosity 
which  serves  as  a  guide  to  find  the  external  part  of  the  tarso-metatarsal 
articulation,  situated  behind.     The  two  extremities  of  the  foot  are 
loose  :  the  posterior  forms  the  heel,  which  projects  behind  the  ankle  ; 
the  heel  is  rounded  posteriorly  and  on  the  sides,  and  flattened  belowr 
and  it  is  callous  in  every  part.     The  anterior  extremity  of  the  foot  is 
divided  like  the  lower  part  of  all  the  limbs  ;  its  segments  constitute  the 
toes,  which  will  be  examined  hereafter. 


TARSO-METATA11SAL  REGION.  355 

Structure.  The  structure  and  the  development  of  the  foot  are  very 
similar  in  their  general  relations  to  those  of  the  hand.  To  show  its 
characters,  we  will  first  remark,  that  in  the  foot,  solidity  is  considered 
at  the  expense  of  mobility  ;  the  tarso-metatarsal  part  is  more  developed 
than  the  anterior  appendages :  the  most  internal  of  the  latter  is  situated 
on  the  same  plane  with  the  others,  and  is  attached  like  them. 

Varieties.  In  the  female,  the  foot  is  smaller  than  in  the  male,  in 
proportion  to  its  height,  and  its  dimensions  are  more  beautiful.  Every 
one  knows  the  false  ideas  of  beauty  attributed  by  certain  nations  to 
the  extreme  smallness  of  the  foot,  which  ideas  cause  the  Chinese  to 
compress  the  feet  of  young  girls,  to  prevent  their  perfect  development, 
to  preserve  that  infantile  grace,  so  much  prized  in  this  country,  but 
for  which  females  endure  much  pain. 

Uses.  The  analogy  of  the  foot  with  the  hand  is  seen  also  in  their 
respective  uses.  Pes  altera  manus,  is  a  very  natural  remark.  This 
analogy,  however  great,  does  not  constitute  a  perfect  similitude ;  in 
fact,  the  foot  is  marked  by  solidity,  the  hand  by  mobility  ;  all  which 
are  sufficiently  proved  by  our  remarks  on  the  structure.  We  shall 
mention,  hereafter,  the  solidity  and  the  relative  motions  of  different 
parts  of  the  foot ;  we  will  only  remark,  that  in  standing,  it  supports 
the  weight  of  the  body,  and  that  its  plantar  face,  which  alone  normally 
touches  the  ground,  rests  upon  it  by  its  extremity  arid  outer  edge  only, 
except  on  a  convex  plane.  In  walking,  the  horizontal  plane  of  the 
foot  rises  successively  from  the  heel  towards  the  toes,  by  bending,  as 
physiologists  say,  in  its  anterior  articulations.  If  this  mechanism  be 
deranged  by  disease,  it  becomes  painful  to  walk  ;  an  instance  of  this 
is  seen  in  anchylosis  of  the  bones  of  the  foot.  The  most  extensive 
motions  of  the  foot  take  place,  as  we  have  seen,  in  the  preceding  region. 
Like  the  hand,  the  foot  is  formed  of  two  distinct  portions,  the  sole  and 
the  toes  ;  we  will  examine  them  in  detail. 


1.   TARSO-METATARSAL   REGION,   OR   REGION 
OP   THE   SOLE   OF   THE   FOOT. 

This  is  the  indivisible  part  of  the  foot,  of  which  it  forms  the  five 
posterior  sixths :  hence,  also,  our  remarks  on  the  external  form  of  the 
foot  generally,  may  be  referred  to  this  region. 

Structure.  —  1.  Elements.  The  skeleton  of  this  region  is  formed 
by  the  tarsus  and  the  metatarsus,  the  bones  of  which  are  more  or  less 
exactly  cuneiform,  are  united  in  an  arch,  the  supports  of  which  are 
represented  by  ligaments :  these  are  stronger  below  than  above  ;  some 
are  arranged  transversely,  others  from  before  backward,  so  that  the 


356  TOPOGRAPHICAL  ANATOMY. 

whole  is  extremely  resisting  in  every  direction.  The  transverse  meta- 
tarsal  ligament,  which  unites  all  the  heads  of  the  metatarsal  bones, 
and  the  plantar  aponeurosis,  the  strong  ligament  of  some  authors,  are 
the  largest :  they  may  be  considered  as  the  cords  of  the  transverse  and 
antero-posterior  arches  of  the  sole  of  the  foot.  Two  of  the  articulations 
deserve  particular  notice,  the  tarso-metatarsal,  and  that  formed  by  the 
os  calcis  and  astragalus  on  one  side,  and  the  scaphoides  and  cuboides 
on  the  other.  The  latter,  the  internal  level  of  which  is  fixed  behind 
the  tuberosity  of  the  scaphoid  bone,  has  its  two  extremities  arranged 
on  a  transverse  plane  ;  while  it  is  even  slightly  curved,  so  as  to  present 
its  convexity  forward.  The  first,  on  the  contrary,  is  generally  oblique 
from  behind  forward,  and  from  without  inward  from  the  centre  of  the 
external  edge  of  the  foot  to  a  similar  point  of  the  internal,  between  the 
tuberosity  of  the  fifth  and  that  of  the  first  metatarsal  bone,  which 
tuberosities  have  already  been  mentioned.  This  articulation,  also, 
presents  some  local  varieties  in  its  direction,  which  must  be  observed  : 
on  the  outside,  the  general  direction  continues :  on  the  inside,  it  is 
transverse  first  at  the  level  of  the  first  metatarsal  bone  ;  it  is  then 
antero-posterior  for  about  three  lines,  and  afterward  again  becomes 
transverse  for  five  lines  ;  finally,  it  goes  forward  and  a  little  outward, 
for  about  two  lines,  and  joins  the  external  part,  the  plane  of  which  has 
been  mentioned ;  so  that  a  real  mortice  is  formed  by  the  three  cunei- 
form bones,  in  which  the  posterior  extremity  of  the  second  metatarsal 
bone  is  received  and  fixed  :  this  interlacing  of  the  articulation  causes 
the  difficulty  of  amputating  at  the  tarso-metatarsal  region.  At  the 
metatarsus,  the  parts  of  the  skeletofy  arjp  separated  by  inter-osseous 
spaces,  which  are  filled  by  the  inter-Qss^i- muscles ;  other  muscles, 
which  are  more  numerous,  rest  on  thrower  -part'-of  the  skeleton,  the 
flexor  digitorum  brevis  cornmunis,  the  lexoV-  a<:ce,ssorius,  the  luinbri- 
-cales,  the  abductor  and  flexor  minimi  digiti^.pedis.,  the  adductor,  the 
flexor  brevis,  the  oblique  and  transverse  abductors  of  the  great  toe : 
one  only  is  situated  above,  the  flexor  brevis:  a  very  strong  ligament, 
the  internal  annular  ligament  of  the  tarsus,  forms  on  the  inside  an 
arch,  on  which  the  adductor  hallucis  muscle  is  situated  :  a  single  and 
very  thin  aponeurosis  is  continuous  with  the  annular  ligament  of  the 
ankle,  and  covers  the  supra-plantar  portion  of  the  sole  of  the  foot. 
The  opposite  face,  on  the  contrary,  presents  an  extremely  strong  layer, 
which  serves  at  the  same  time  as  an  envelope,  and  as  points  of  insertion 
for  the  muscles,  and  also  as  a  ligament  for  the  skeleton  ;  it  has  already 
been  named  ;  it  is  the  plantar,  or  rather  the  sub-plantar  aponeurosis  : 
this  aponeurosis  is  narrow  posteriorly,  but  is  expanded  anteriorly,  and 
is  separated  into  five  slips,  which  go  on  the  transverse  metatarsal 
4ig.am.ent,  on  which  they  are  attached  by  a  bifurcation,  the  branches 


TARSO-METATARSAL  REGION.  357  • 

of  which  embrace  the  heads  of  the  metatarsal  bones.  Posteriorly,  this 
aponeurosis  adheres  intimately  to  the  posterior  tuberosity  of  the  os 
calcis,  and  is  very  thin  on  its  edges  :  its  cutaneous  face  is  attached  to 
the  skin  by  fibrous  bands,  which  will  be  described  hereafter :  its  deep 
face  gives  origin  to  many  fibres  of  the  superficial  muscles,  between 
which,  also,  it  sends  some  imperfect  septa,  which  fulfil  the  same  object. 
The  arteries  of  the  tarso-metatarsal  portion  of  the  foot  come  almost 
exclusively  from  the  dorsal  artery  of  the  foot,  and  from  the  external 
and  internal  plantar  arteries  ;  the  first  two  communicate  by  an  anasto- 
motic  plexus,  which  embraces  most  of  the  sole  of  the  foot,  and  establishes 
mutual  relations  between  the  supra-  and  sub-plantar  circulation^. 
Among  the  secondary  arteries,  we  may  mention  principally  the  dorsal 
arteries  of  the  tarsus  and  metatarsus,  which. anastomose  on  the  edges 
of  the  foot  with  the  inferior  arteries,  and  near  the  ankle  with  the 
malleolar  and  the  two  peroneal  arteries,  so  as  to  establish  a  very  im- 
portant collateral  circulation  between  the  superior  and  inferior  arterial 
systems  of  the  sole  of  the  foot,  and  also  between  the  latter  and  that  of 
the  ankle.  Two  large  dorsal  and  external  plantar  veins  arise  deeply 
from  the  supra-  and  sub-plantar  faces,  and  strictly  follow  the  arteries 
of  the  same  name,  and  like  them,  anastomose  anteriorly.  Two  smaller 
veins  attend  the  internal  plantar  artery.  All  these  deep  vessels  commu- 
nicate with  the  superficial  vessels,  particularly  at  the  inner  edge  of  the 
region  ;  the  superficial  veins  form  on  the  back  of  this  an  arch,  convex 
anteriorly,  which  receives  the  digital  veins,  and  also  those  from  the  in- 
side and  outside  of  the  sub-cutaneous  parts  of  the  sub-plantar  face,  and 
then  go  toward  the  ankle,  where  they  form  the  saphenae.  The  superficial 
lymphatic  vessels  go  directly  to  the  superficial  ganglions  of  the  groin  : 
the  deep  come  to  them,  after  passing  through  the  anterior  tibial  and 
popliteal  ganglions.  The  nerves  of  the  tarso-metatarsal  part  of  the 
foot  are  also  superficial  and  deep :  the  deep  are  given  off  to  the  back 
by  the  end  of  the  anterior  tibial,  and  the  superficial  are  ramifications 
of  the  two  saphenae  and  of  the  musculo-cutaneous  nerves.  In  the 
lower  face,  the  two  proper  plantar  nerves  give  off  deep  filaments, 
among  which,  the  distribution  of  the  external  resembles  that  of  the 
ulnar  nerve,  while  that  of  the  internal  differs  but  little  from  that  of  the 
median  nerve  in  the  hand :  both  give  off  some  superficial  filaments, 
and  others  come  from  the  external  saphena.  The  cellular  tissue  is 
very  loose  on  the  back ;  it  is  there  almost  destitute  of  fat :  on  the 
lower  face,  on  the  contrary,  it  is  remarkable  for  its  fibrous  density,  and 
forms  vertical  canals,  which  are  attached  by  one  extremity  to  the  skin, 
and  by  the  other  to  the  plantar  aponeurosis,  in  which  some  adipose 
vesicles  are  situated,  which  are  numerous  in  the  heel  and  at  the  heads 
#f  the  metatarsal  bones.  The  skin  is  fine  above  ;  it  is  thicker  below, 


358  TOPOGRAPHICAL  ANATOMY. 

where  it  is  constantly  exposed  to  pressure :  it  is  callous,  especially 
anteriorly  and  posteriorly. 

2.  Relations.  Let  us  now  study  the  respective  relations  of  all  these 
elements  ;  and  in  order  to  this,  we  will  examine,  successively,  the  two 
faces,  the  supra-  and  sub-plantar  faces,  the  limits  of  which  are  so 
marked,  that  no  one  can  mistake  them. 

1.  Supra-plantar  face.     The  diiferent  layers  which  form  the  back 
of  this  part  of  the  foot,  are  ;  the  skin,  a  very  loose  and  slightly  adipose 
cellular  layer,  containing,  with  the  dorsal  venous  arch  and  the  super- 
ficial lymphatic  vessels,  the  end  of  the  saphense  nerves  on  the  inside 
and  outside,  and  in  the  centre,  two  terminating  branches  of  the  mus- 
culo-cutaneous  nerve  :  the  dorsal  aponeurosis,  the  tendons  of  the  tibialis 
posticus,  tibialis  anticus,  extensor  hallucis  proprius,  extensor  communis, 
and  of  the  peroneus  longus  and  brevis,  all  of  which  are  arranged  from 
within  outward,  in  the  order  mentioned,  and  are  situated  on  the  same 
plane ;  the  flexor  digitorum  communis  brevis  muscle  on  the  outside, 
and  on  the  inside  the  dorsal  artery  and  veins,  which  follow  the  internal 
edge  of  the  foot,  on  the  outside  of  the  tendon  of  the  extensor  hallucis 
proprius,  to  which  one  of  the  terminating  branches  of  the  anterior 
tibial  nerve  is  contiguous,  not  being  covered  by  the  flexor  communis 
digitorum  brevis  muscle,  except  in  the  centre  of  the  foot,  where  they 
are  crossed  by  its  inner  tendon :  finally,  some  vessels,  which  descend 
through  the  first  inter-osseous  space ;  the  arch  of  the  dorsal  artery  of 
the  tarsus,  attended  by  the  external  branch  of  the  anterior  tibial  nerve, 
and  entirely  concealed  by  the  flexor  digitorum  communis  brevis  muscle ; 
finally,  the  convex  part  of  the  arch,  represented  by  the  skeleton  of  the 
tarso-metatarsal  part  of  the  foot,  which  contains   anteriorly,  in  its 
spaces,  the  four  inter-ossei  muscles. 

2.  Sub-plantar  face.     Here  the  organs  become  more  numerous,  and 
their  arrangement  is  necessarily  more  complex  :  they  are  all  situated 
in  the  concavity  of  the  tarso-metatarsal  skeleton.     The  skin  forms 
there  a  first  layer,  and  is  remarkable  for  its  strength  and  thickness  in 
the  points  we  have  already  mentioned  :  it  is  lined  in  every  part  by  a 
cellulo-fatty  cushion,  which  is  thinner  in  the  centre,  and  the  anato- 
mical arrangement  of  which  is  very  curious  and  remarkable  in  tall 
and  heavy  animals  ;   in  this  layer  some  filaments  of  the  external 
saphena  and  plantar  nerves  ramify,  and  also  the  branches  of  the  posterior 
peroneal  artery.     The  sub-plantar  aponeurosis  forms  the  third  layer : 
more  deeply,  come  the  muscles,  vessels,  and  the  most  important  nerves. 
Near  the  inner  edge,  and  in  a  point  analogous  to  the  thenar  eminence 
of  the  hand,  we  find,  superimposed  from  below  upward,  posteriorly,  the 
origin  of  the  adductor  hallucis  proprius  muscle,  the  plantar  vessels  and 
nerves,  and  finally,  the  tendons  of  the  flexor  digitorum  communis 


TARSO-METATARSAL  REGION.  359 

longns  and  flexor  hallucis  proprius,  crossing  so  that  the  latter  becomes 
internal ;  anteriorly,  the  end  of  the  abductor  hallucis,  the  tendon  of  its 
long  flexor,  and  the  collateral  vessels  and  nerves  of  this  toe,  parts 
which  form  a  plane,  under  which  the  flexor  brevis  muscle  is  seen, 
which  is  attached  to  the  first  metatarsal  bone.  Near  the  external  edge, 
in  another  place,  analogous  to  the  hypo-thenar  eminence  of  the  hand, 
we  remark,  first  the  adductor  minimi  digiti  pedis,  resting  posteriorly 
on  the  bones,  in  the  centre  on  the  oblique  tendinous  sheath  of  the 
peroneus  longus  muscle,  finally,  anteriorly  on  the  flexor  minimi  digiti 
muscle,  which  adheres  to  the  fifth  metatarsal  bone.  Between  these 
two  points,  the  flexor  communis  forms  the  first  layer,  the  plantar 
vessels  and  nerves  the  second,  in  which,  however,  we  do  not  find  the 
end  of  the  plantar  arch :  the  flexor  accessorius  muscle,  the  tendons  of 
this,  and  those  of  the  flexor  hallucis  longus,  the  lumbricales  muscles 
form  the  third  ;  below  appear  posteriorly,  the  bones  and  the  strong 
ligaments  which  unite  them,  while  anteriorly,  we  find  also  the  trans- 
verse abductor  muscle,  under  the  heads  of  the  metatarsal  bones,  and 
the  ligament  which  unites  them,  then  the  oblique  abductor  muscle, 
which  conceals  the  end  of  the  plantar  arch,  the  deep  filament  of  the 
external  plantar  nerve,  the  central  bones  of  the  metatarsus,  the  inter- 
ossei  muscles  which  separate  them,  and  the  end  of  the  sheath  of  the 
peroneus  longus  muscle. 

Development.  Although  the  foot  appears  before  the  hand  in  the 
fetus,  the  skeleton  of  the  sole  of  the  foot  begins  to  ossify  before  that  of 
the  palm  of  the  hand,  which  is  analogous  to  it  in  the  thoracic  limb. 
The  different  uses  of  these  two  parts  explain  this  fact  satisfactorily. 
During  infancy,  the  plantar  cushion  presents  but  little  resistance,  the 
skin  which  covers  it  is  thin,  not  callous,  and  the  arch  of  the  tarsus  is 
not  very  distinct,  all  which  circumstances  contra-indicate  the  erect 
posture  at  this  age. 

Varieties.  Besides  the  varieties  in  the  general  form,  which  we  shall 
mention,  the  sole  of  the  foot  presents  some  special  varieties,  which  are 
very  important :  thus  we  have  found  in  two  cadavers  four  cuneiform 
bones,  and  the  cuboid  bone  corresponded  to  the  last  metatarsal  bone. 
From  whatever  source  the  arteries  of  the  sole  of  the  foot  arise,  it  is  of 
little  importance  to  the  region,  provided  their  arrangement  is  normal ; 
but  sometimes,  anomalies  in  origin  are  attended  with  those  of  position  : 
hence,  sometimes  the  dorsal  artery  of  the  foot  arises  from  the  anterior 
peroneal  artery,  and  is  situated  in  the  middle  of  the  back  of  the  foot, 
under  the  flexor  digitorum  communis  brevis  muscle. 

Uses.  The  tarso-metatarsal  section  of  the  foot  forms  its  most  solid 
and  resisting  part;  this  supports  the  weight  of  the  whole  body  in 
standing,  whence  the  immense  importance  of  the  sub-plantar  arch. 


360  TOPOGRAPHICAL  ANATOMY. 

which  protects  the  vessels,  muscles,  and  nerves  from  a  pressure,  which 
would  cause  severe  pain,  and  would  also  injure  their  functions ;  in 
standing,  however,  on  an  uneven  and  convex  surface,  the  vessels  may 
be  compressed,  which  accounts  for  the  broad  vascular  anastomoses 
between  the  two  faces  of  this  region.  Remark  also  the  admirable  pre- 
cautions taken  by  nature  for  standing  and  walking ;  she  has  increased 
the  density  of  the  skin  of  the  lower  face  of  the  foot,  and  has  lined  it 
with  an  elastic  cushion,  which  prevents  it  from  rubbing  on  the  surfaces 
of  bone :  finally,  the  different  parts  of  this  plantar  cushion  have  a 
fibrous  envelope,  the  resistance  of  which  is  calculated  according  to  the 
weight  of  the  animal  ;*  this  envelope  prevents  an  increase  in  the 
breadth  of  the  adipose  bodies,  which  would  diminish  their  protection 
of  the  skin.  Farther,  the  concavity  of  the  sub-plantar  face  of  the  foot 
presents  another  advantage  also,  that  of  facilitating  walking,  especially 
on  an  ascending  plane ;  as  the  sole  of  the  foot  can  thus  embrace  the 
inequalities  of  the  soil,  and  be  in  a  measure  hooked  with  it.  Tn 
standing  or  walking,  the  inferior  •  ligaments,  the  true  supports  of  the 
tarso-metatarsal  arch,  are  much  fatigued  by  their  constant  tension, 
hence  severe  pains  or  an  aching  of  the  feet.  In  order  to  understand 
the  mechanism  of  the  ankle,  we  have  already  mentioned  the  manner 
in  which  the  inner  edge  of  the  foot  rests  on  the  ground  :  we  shall, 
therefore,  omit  it  in  this  place  :  the  special  motions  of  this  region  are 
very  obscure  and  unimportant,  except  those  of  the  astragalus  on  the 
scaphoides  and  the  os  calcis  ;  but  those  belong  to  the  ankle,  as  we  have 
seen.  We  have  mentioned  the  extreme  sensibility  of  the  skin  of  the 
sole  of  the,  foot,  and  particularly  the  close  sympathy  between  it  and 
the  diaphragm,  so  that-  the  slightest  tickling  of  this  part  causes  the 
most  rapid  convulsions  of  this  muscle,  and  all  the  phenomena  of 
laughing.  Finally,  although  remote  from  the  centre  of  the  circula- 
tion, the  sole  of  the  foot,  like  the  palm  of  the  hand,  is  habitually  very 
warm,  and  the  seat  of  an  abundant  exudation,  especially  in  some 
individuals. 

Pathological  and  operative  deductions.  In  some  individuals,  the 
plantar  arch  hardly  exists,  and  in  standing,  the  whole  foot  rests  on  the 
ground;  hence,  difficulty  of  walking  and  pains;  this  deviation  of 
formation  is  termed  pied-plat,  or  flat  foot.  Sometimes  the  sole  of  the 
foot  does  not  touch  the  ground,  this  is  the  pied-equin,  a  deviation  of 
formation,  in  which,  as  in  the  digitigrade  animals,  the  toes  alone 
serve  as  a  base  of  support ;  finally,  the  sole  of  the  foot  is  sometimes 
permanently  rotated,  club-foot;  in  these  cases,  sometimes  the  back 
and  sometimes  the  lower  face  of  the  sole  of  the  foot  are  directed  inward, 

*  The  horse,  the  elephant,  and  the  lion,  arc  remarkable  in  this  respect. 


TARSO-METATARSAL  REGION.  361 

the  external  or  internal  edges  resting  on  the  ground;  the  ancients 
termed  the  former  kind  valgi,  and  the  last  vari.     We  have  already 
mentioned  the  manner  in  which  they  are  produced.     Wounds  of  the 
sole  of  the  foot  may  penetrate  from  one  of  its  faces  to  the  other,  ante- 
riorly, at  the  metatarsus  ;  those  which  affect  exclusively  the  inferior 
soft  parts  are  much  more  serious  than  the  superior,  on  account  of  the 
number  of  vessels  and  nerves  in  this  direction ;  in  the  torrid  zone, 
these  wounds  frequently  cause  symptoms  of  tetanus ;  doubtless,  the 
imperfect  injury  of  the  nerves,  and  the  pains  which  result  from  them, 
are  the  causes  of  these  symptoms.     If  the  dorsal  artery  of  the  foot  be 
wounded,  it  may  easily  be  tied  along  the  outer  side  of  the  tendon  of 
the  extensor  hallucis  proprius,  which  is  .readily  seen  by  flexing  the 
great  toe  ;  the  external  plantar  artery  may  be  tied  in  many  points.     In 
looking  for  the  dorsal  artery  of  the  foot,  the  surgeon  must  not  forget 
that  it  may  be  abnormally  situated  on  the  outside,  as  we  have  stated, 
and  then  it  cannot  be  found  by  cutting  on  the  external  edge  of  the 
tendon  of  the  extensor  muscle  mentioned  above.     The  tarso-metatarsal 
skeleton  is  formed  so  firmly,  and  its  different  parts  are  so  thick,  that 
great  force  is  necessary  to  fracture  it ;  these  fractures  are  frequently 
produced  by  the  fall  of  a  heavy  body,  or  by  the  wheel  of  a  vehicle,  and 
then  all  the  elements  of  the  foot  are  crushed  ;  this  injury  generally 
requires  amputation.     If  we  except  dislocation  of  the  astragalus,  which 
we  have  already  mentioned,  this  accident  seldom  occurs  in  the  sole  of 
the  foot,  the  articulation  of  which  is  extremely  compact,  and  admits  of 
but  slight  motions.     In  standing  and  walking,  the  foot  swells  because 
its  vascular  plexus  is  distended  ;  this  is  the  reason  why  a  'shoe  which 
at  first  appears  to  fit  becomes  much  too  small  and  painful ;  for  the 
same  reasons,  the  transverse  diameter  of  the  sole  of  the  foot  increases 
a  little,  and  the  two  edges  of  the  foot  are  pressed  with  a  much  greater 
force,  and  become  more  and  more  prominent,  by  the  slight  collapse  of 
the  plantar  arch  ;  ampulla  or  phlyctense  are  the  first  effects  of  this 
pressure,  when  continued  for  any  time  ;  if  this  exist  for  whole  months, 
it  produces  callosities,  or  corns  ;  the  first  are  simply  indurations  of  the 
epidermis  ;  the  second  consist  in  the  accidental  formation  of  a  sub- 
cutaneous mucous  bursa,  in  which  synovia  accumulates.     The  skin 
of  the  sub-plantar  region  of  the  foot  is  always  the  seat  of  a  fetid  trans- 
udation,  the  suppression  of  which  has  often  caused  serious  symptoms  ; 
its  extreme  abundance  is  considered  by  Lobstein  as  a  disease  ;  it  is, 
perhaps,  rather  a  symptom  of  disease.     The  dryness  or  the  moisture  of 
the  sole  of  the  foot,  and  its  greater  or  less  degree  of  heat  and  cold, 
furnish  pathologists  with  important  signs  in   deep  diseases   of  the 
organism.     The  sympathetical  relations  between  the  diaphragm  and 
the  sole  of  the  foot  have  been  employed  to  cause  respiration  in  newly 

46 


362  TOPOGRAPHICAL  ANATOMY. 

born  children,  or  to  re-establish  it  in  persons  who  have  been  suffocated ; 
finally,  this  part,  by  its  sensibility,  its  sympathy,  and  the  number  of  its 
vessels,  seems  very  proper  for  revulsive  applications,  which  are  daily 
used.  Inflammation  of  the  back  of  this  region  is  less  serious  and  less 
painful  than  in  the  opposite  face  ;  the  resistance  of  the  skin  and  of  the 
aponeurosis,  which  is  very  great  in  this  latter  point  and  less  in  the 
first,  and  particularly  the  differences  which  have  been  mentioned  in 
the  sub-cutaneous  tissue,  are  evidently  the  causes  of  this  pathological 
difference. 

We  have  observed  at  the  Hospice  Bicetre  an  individual,  in  whom 
the  motions  of  the  foot  were  very  stiff;  it  could  not  be  flexed  in 
walking,  which  caused  a  continual  lameness ;  upon  post  mortem  exa- 
mination, we  found  an  anchylosis  of  the  whole  plantar  part  of  the  foot. 
Partial  anchylosis  of  the  bones  of  the  foot  is  much  more  common,  and 
causes  much  less  trouble.  Different  diseases  may  require  an  amputa- 
tion of  the  foot  in  different  points ;  its  extirpation  is  never  necessary. 
Amputations  may  be  performed  in  the  tarso-metatarsal  articulation,  or 
in  that  of  the  astragalus  and  os  calcis,  with  the  scaphoides  and  cuboides  : 
in  the  latter,  which  Chopart  has  described,  and  which  Richerand  has 
improved  by  using  the  relations  of  the  tuberosity  of  the  scaphoides 
with  the  articulation,  all  the  flexor  tendons  of  the  foot  are  divided, 
while  the  extensors  are  uninjured ;  hence,  the  stump  is  turned  over  in 
the  direction  of  extension,  and  in  walking,  its  cicatrix  presses  on  the 
ground.  The  amputation  in  the  tarso-metatarsal  articulation,  for 
which  Lisfranc  has  proposed  a  very  advantageous  process,  is  more 
difficult,  and  is  applicable  to  fewer  cases,  but  it  presents  the  very  great 
advantage  of  preserving  in  the  sole  of  the  foot  its  flexor  and  extensor 
tendons,  which  facilitates  standing  and  walking.  Farther,  Lisfranc's 
process  is  founded  strictly  on  the  anatomical  arrangement  of  this 
region  :  in  order  to  perform  it,  we  must  remember,  first,  that  the  soft 
parts  are  thin  upon  the  back  of  the  foot,  while  the  sub-plantar  muscles 
are  extremely  thick ;  hence  the  direction  to  form  a  single  inferior 
flap ;  second,  that  the  tarsal  articular  surfaces  are  very  high  on  the 
inside,  and  lower  on  the  outside  ;  hence  the  precept,  to  make  the  short 
flap  in  this  latter  direction,  and  the  long  in  the  first  direction,  rounding 
it  from  without  inward ;  third,  that  the  level  of  the  articulation  on  the 
inside  corresponds  to  the  centre  of  the  internal  edge  of  the  foot,  while 
on  the  outside,  it  is  more  evidently  situated  behind  the  tuberosity  of 
the  fifth  metatarsal  bone ;  fourth,  that  the  articular  line,  which  is 
generally  oblique  inward  and  from  behind  forward,  is  a  little  curved. 
The  two  plantar  arteries  below,  and  above,  the  dorsal  artery  of  the 
foot  and  the  dorsal  artery  of  the  metatarsus,  must  be  tied  after  this 
operation.  Bouchet,  of  Lyons,  has  extirpated,  with  success,  the  last 


TOES.  363 

three  metatarsal  bones  and  their  corresponding  toes  ;  we  may  extirpate 
even  the  internal,  but  the  operation  is  much  more  serious,  -if  not 
directly,  at  least  in  its  consequences ;  for  in  standing  and  walking,  the 
head  of  the  first  metatarsal  bone  affords  a  useful  point  of  support  for 
the  inner  edge  of  the  foot.  We  cannot  tell  from  experience  what 
would  happen  in  this  case,  but  anatomy  would  lead  to  the  opinion 
that  standing  would  be  painful,  and  that  the  foot  would  turn  so  that 
its  lower  face  would  be  outward.*  For  these  reasons,  we  consider 
amputation  of  the  first  metatarsal  bone  as  rational  only  in  cases  where 
its  head  is  diseased ;  in  any  other  case,  we  think  it  better  simply  to 
extirpate  the  great  toe.  We  think  that  the  opposite  course  has  been 
regarded  too  lightly  by  authors. 


2.       OP      THE      TOES. 

The  toes  are  the  terminating  appendages  of  the  foot.  They  esta- 
blish the  greatest  analogies  between  the  foot  and  the  hand ;  hence  we 
might  refer  for  their  description  to  that  of  the  fingers  ;  this,  however, 
is  inadmissible,  since,  in  considering  the  toes  and  fingers  as  very 
analogous,  we  must  not  pass  over  the  differences  which  characterize 
the  former. 

The  toes  are  five  in  number,  and  have  no  special  name,  except  the 
extreme  two,  which  are  known  as  the  great  and  the  little  toe ;  the 
others,  and  even  these,  are  termed  by  their  numerical  position,  from 
within  outward. 

The  length  of  the  toes  is  such,  that,  in  the  natural  state,  the  second 
exceeds  all  the  others,  next  comes  the  first,  and  then  the  others  follow 
Successively,  from  within  outward.  The  second  toe  is  analogous  to 
the  middle  finger  in  the  hand,  not  only  in  respect  to  its  length,  but 
also  in  the  arrangement  of  its  muscles. 

All  the  toes,  except  the  first  toe,  are  generally  curved  downward  ; 
this  direction,  however,  is  increased  by  the  pressure  of  narrow  shoes; 
the  toes,  in  the  natural  state,  are  all  situated  on  the  same  plane  ;  the 
first  is  not  more  moveable  than  the  others,  an  arrangement  which 
characterizes  the  foot. 

The  toes  are  shorter,  and,  if  we  except  the  first,  are  smaller  than 
the  fingers.  These  are  almost  the  only  points  in  which  their  external 

*  This  opinion  is  confirmed  by  a  recent  case:  an  unfortunate  peasant,  who  had  lost  his 
great  toe  and  the  metatarsal  bone  which  supported  it,  came  to  the  Central  Bureau  for  ad- 
mission to  the  hospitals ;  his  foot  presented  the  deformity  we  have  stated,  whenever  it  was 
rested  on  the  ground.  It  was  difficult  to  dissuade  him  from  having  more  of  the  foot  removed, 
as  he  had  been  advised. 


364  TOPOGRAPHICAL    ANATOMY. 

surfaces  differ,  We  will  also  add,  and  it  is  extremely  important,  that 
the  attached  extremity  of  the  toes  is  concealed  more  deeply  than  that 
of  the  fingers,  the  inter-digital  membrane,  which  unites  them  in  the 
fetus,  continuing  in  a  greater  extent ;  the  base  of  the  inter-digital 
angle  of  the  toes  is  ten  lines  distant  from  the  metatarso-phalangean 
articulation. 

Structure.  If  we  except  the  first  toe,  the  toes  have  the  structure  of 
the  fingers  in  miniature.  The  phalanges  are  equal  in  number  and 
similar  in  form,  and  are  united  by  articulations  which  resemble  those 
of  the  fingers  ;  they  form  their  skeleton  ;  some  sesamoid  bones  develop 
themselves  more  promptly  than  in  the  fingers,  in  the  anterior  ligaments 
of  their  articulations,  which  must  doubtless  be  attributed  to  the  greater 
and  more  constant  friction  exercised  on  them  by  their  flexor  muscles. 
In  respect  to  the  extensor  muscles,  the  toes,  in  general,  are  better  pro- 
vided than  the  fingers ;  they  have  two  common  extensors,  a  large  and 
a  small ;  this  latter  sends  no  tendon  to  the  small  toe,  and  the  former 
sends  none  to  the  large  toe,  which  has  its  proper  extensor.  The  lum- 
bricales  muscles  of  the  last  four  toes  join  their  extensors,  and  contribute 
to  form  their  dorsal  fibrous  membrane.  Finally,  the  great  toe  and  the 
second  toe  have  two  extensors,  like  the  index  finger  and  the  thumb  ; 
the  third  and  the  fourth  toes  have  one  more  than  the  middle  and  ring 
fingers  ;  the  little  toe,  however,  is  not  so  well  provided  for  as  the  little 
finger,  as  it  has  only  a  tendon  of  the  common  extensor,  which,  how- 
ever, is  frequently  joined  by  a  tendinous  slip  from  the  tendon  of  the 
peroneus  anticus  muscle.*  The  flexor  tendons  of  the  toes  resemble 
those  of  the  fingers  in  respect  to  the  number  and  arrangement  of  the 
sheaths  which  envelope  them  ;  they  differ  only  in  respect  to  the  un- 
equal size  of  their  tendons,  and  also  because  the  longest  flexor  is  pha- 
langettian.  Some  lateral  adductor  and  abductor  muscles  exist  here,  as 
in  the  hand ;  the  great  toe  has  an  internal  and  two  external,  one  of 
which  is  oblique,  and  the  other  transverse ;  in  this  respect,  it  is  better 
provided  for  than  the  thumb.  In  the  others,  the  arrangement  is  the 
same  as  in  the  fingers,  except  that  the  adductor  and  abductor  muscles 
of  the  second  toe  come  from  the  dorsal  inter-ossei ;  while  in  the  hand, 
on  the  contrary,  this  character  is  presented  only  by  the  middle  finger. 
The  arteries,  veins,  and  lymphatic  vessels,  are  arranged  exactly  as  in 
the  fingers.  The  nerves  are  also  similar  :  on  the  back,  they  come 
from  the  musculo-cutaneous  and  the  saphenae  nerves  ;  the  filaments  of 
these  latter  are  confined,  in  the  normal  state,  to  the  great  and  little  toes. 
In  the  lower  face,  the  nerves  of  the  toes  are  given  off  by  the  plantar 


*  The  peronous  anticas  is  analogous  to  the  proper  extensor  of  the  little  finger,  which  in  the 
foot  has  received  another  destination. 


TOES.  365 

nerves  ;  the  internal  sends  twigs  to  the  first  three  toes,  and  to  the  inner 
side  of  the  fourth,  as  does  the  median  nerve  to  the  fingers  ;  the  external 
extends  to  the  little  toe,  and  to  the  outer  edge  of  the  fourth ;  it  is 
analogous  to  the  ulnar  nerve.  The  skin,  the  nails,  the  cellular  and 
adipose  tissues,  have  no  characters  which  have  not  been  mentioned 
when  speaking  of  the  fingers.  We  often  find  a  mucous  bursa  on  the 
inside  of  the  metatarso-phalangean  articulation  of  the  great  toe.  Not- 
withstanding the  analogy  which  approximates,  as  we  have  seen,  the 
elements  of  the  toes  and  those  of  the  fingers,  we  have  pointed  out  the 
differences  between  them  ;  but  the  relations  of  their  elements  are  almost 
perfectly  similar,  and  hence,  details  on  this  subject  would  be  merely 
repetitions,  after  we  have  described  the  relations  of  the  fingers. 

Development.  The  toes  are  the  first  part  of  the  pelvic  limbs  and 
of  the  foot  which  are  well  marked  in  the  fetus.  We  have  already 
mentioned  the  membrane  which  unites  them  all  in  the  early  periods  ; 
we  add,  that  their  separation  commences  late  and  is  soon  arrested,  so 
that  in  the  normal  state,  and  even  in  the  adult  man,  the  toes  are  also 
united  at  their  base,  to  a  certain  extent,  almost  as  in  the  gallinaceous 
birds. 

Varieties.  In  children,  the  toes  are  almost  straight,  and  very 
moveable,  as  the  natural  proportions  are  not  yet  destroyed ;  but  at  a 
later  period,  the  use  of  shoes  arrests  their  growth,  and  causes  them  to 
assume  a  very  curved  form,  so  that  they  frequently  touch  the  ground, 
not  by  the  whole  of  their  lower  face,  but  by  their  ungual  extremity 
only ;  their  mobility  often  decreases  very  much,  and  they  become  stiff 
in  consequence  of  the  fusion  of  their  phalanges.  When  the  nails  are 
left  to  themselves,  they  grow  slowly,  but  almost  indefinitely,  and 
assume  the  curved  form  of  the  claws  of  carnivorous  animals. 

The  most  special  varieties  of  the  elements  of  the  toes  are  unimpor- 
tant ;  they  produce  no  modification  in  the  general  arrangement  which 
has  been  mentioned  ;  these  varieties  consist  particularly  in  the  increase 
or  diminution  of  the  tendons  of  the  extensor  or  flexor  muscles  ;  all  the 
others  are  similar  to  those  of  the  fingers. 

Uses.  The  toes  admit  the  motions  of  flexion,  extension,  adduction, 
abduction,  or  circumduction.  Sometimes,  they  alone  support  the 
weight  of  the  whole  body,  as  in  standing  on  the  end  of  the  feet ;  this 
is  their  common  function  in  the  digitigrade  animals.  In  walking,  and 
in  all  its  varieties,  the  toes  are  detached  from  the  ground  by  a  motion 
of  rotation,  the  centre  of  which  is  situated  in  their  ungual  extremity, 
which  is  supported  the  last. 

Pathological  and  operative  deductions.  The  number  of  the  toes 
may  be  greater  or  less  than  in  the  normal  state,  as  has  been  said  ;  in 
the  first  case,  which  is  more  rare,  sometimes  the  supernumerary  toe 


366  TOPOGRAPHICAL  ANATOMY. 

has  the  texture  of  the  others,  sometimes  it  has  only  their  form,  being 
simply  a  vegetation,  which  may  be  removed  with  a  knife.  This 
excess  of  number  has  been  observed  to  be  constant  in  certain  families. 
All  or  some  of  the  toes  may  be  united  as  far  as  their  loose  extremity  ; 
sometimes,  as  we  have  observed,  they  are  imperfectly  separated  ;  these 
deviations  of  formation,  which  are  simply  caused  by  an  arrest  of  de- 
velopment, may  easily  be  remedied  by  incisions.*  Narrow  shoes  often 
cause  the  forced  flexion  of  the  toes  ;  at  the  commencement,  this  devia- 
tion may  be  arrested  by  rest  and  the  use  of  larger  shoes  ;  but  when 
long  continued,  the  phalangean  and  metatarso-phalangean  articulations 
are  deformed,  and  the  toe  always  preserves  its  wrong  direction ;  this 
deviation  may  also  result  from  the  retraction  of  an  extensor  tendon, 
the  division  of  which  has  sometimes  cured  the  disease.  In  these  cases, 
the  extremities  of  the  toe  and  toe-nail  rest  on  the  ground,  in  standing ; 
hence,  severe  pains,  which  render  this  almost  impossible ;  pains  which 
are  produced  by  the  crowding  of  the  nail  into  the  matrix  which  sur- 
rounds it ;  these  morbid  phenomena  are  also  much  more  marked  in 
walking,  at  the  moment  when  the  pulp  of  the  toe  is  detached  from  the 
ground,  after  the  rotatory  motion  we  have  mentioned  ;  in  these  cases, 
the  extirpation  of  the  toe  is  often  the  only  mode  of  cure.  In  standing 
and  in  walking,  the  pulp  of  the  toes  being  pressed  by  the  ground, 
forces  the  nail  from  below  upward ;  and  when  this  is  cut  too  short, 
and  its  extremity  does  not  extend  beyond  that  of  the  toe,  its  angles 
irritate  it,  and  cause  the  inflammation  of  the  fold  of  skin  which 
surrounds  it ;  the  long  continued  pressure  of  shoes  upon  the  extremity 
of  the  nail  causes  the  same  result,  by  crowding  back  the  sharp  and 
attached  edge  of  the  nail  against  the  base  of  its  matrix.  This  is  the 
very  painful  inflammation  described  as  onyxis ;  as  it  affects  the  secre- 
tory organ  of  the  nail,  it  may  be  attended  with  different  alterations  of 
the  nail,  as  its  loss,  its  softening,  &c.  The  pressure  of  shoes,'  which 
produces  most  of  the  diseases  of  these  small  organs,  is  also  the  cause 
of  the  development  of  corns ;  tumors  always  form  by  a  kind  of  local 
hypertrophy  of  the  horny  layer  of  the  skin ;  the  thickening  of  the 
epidermis,  which  is  also  remarked,  is  entirely  accessory.  On  the  inner 

*  Since  this  article  and  that  on  the  fingers  were  written,  we  have  seen  a  hand  in  which  only 
two  fingers  existed  ;  the  most  external,  which  at  first  view  resembled  the  thumb,  was  clearly 
formed  by  the  fusion  of  the  thumb  and  index  finger  ;  in  fact,  its  first  phalanx  rested  on  the 
two  rnetacarpal  bones,  and  although  it  presented  a  phalanx  and  a  phalangette,  we  also  found, 
in  the  inner  part  of  the  articulation  which  united  these  two  bones,  a  rudiment  of  the  phalangine. 
The  other  finger  corresponded  to  the  middle  finger  in  length  ;  it  was  formed  as  in  the  normal 
state.  Farther,  in  the  same  preparation,  there  were  only  three  rnetacarpal  bones ;  the,  first  two 
were  articulated  superiorly  and  inferiorly,  and  in  this  latter  direction  they  were  united,  as  we 
have  already  said,  with  the  first  finger.  We  could  easily  discover  all  the  bones  of  the  carpus, 
but  they  were  all  fused  and  united  in  one. 


TOES.  367 

face  of  the  metacarpo-phalangean  articulation  of  the  great  toe,  we  often 
find  a  chronic  engorgement  of  another  character ;  this  is  a  real  gan- 
glion, developed  in  the  mucous  bursa  which  has  been  mentioned  ;  we 
have  dissected  several  of  them,  and  have  never  seen  that  the  cyst 
communicated  with  the  synovial  membrane  of  the  adjacent  articulation, 
as  some  authors  assert.  The  toes,  like  the  fingers,  may  be  diseased 
with  panaris ;  they  are  soon  affected  with  cold,  and  then  gangrene 
easily  supervenes :  it  is  asserted  that  this  is  caused  by  the  distance  of 
the  toes  from  the  centre  of  the  circulation ;  anatomy,  however,  has 
shown  us,  that  the  circulation  of  the  toes  is  very  active,  and  takes 
place  by  very  numerous  vessels,  in  proportion  to  the  size  of  the  organs : 
this  is  a  precaution  taken  by  nature,  as  in  many  other  extreme  points 
of  the  body,  the  nose  and  the  ears,  in  order  to  correct,  as  much  as 
possible,  this  tendency  to  chill,  and  consequently  to  congelation ;  this 
precaution  demonstrates,  that  the  above  explanation  is  perfectly  gra- 
tuitous. The  broad  surface  by  which  these  parts  are  exposed  to  the 
air,  and  the  rapid  chill  which  then  ensues,  is  the  true  and  the  only 
cause  which  can  be  admitted.  The  phalanges  of  the  toes  are  rarely 
amputated,  but  their  extirpation  is  admissible,  for  which  we  must  not 
substitute  the  amputation  of  the  metatarsal  bones,  except  when  their 
heads  are  diseased.  Farther,  this  extirpation  is  more  difficult  than 
that  of  the  fingers,  on  account  of  the  deeper  position  of  the  metatarso- 
phalangean  articulation. 


THE       END. 

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